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Setting priorities in health care organizations: criteria, processes, and parameters of success

Setting priorities in health care organizations: criteria, processes, and parameters of success Background: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. Discussion: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. Summary: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly. Background ities [10-16]. However, very little has been reported from Hospitals and regional health authorities in Canada and the perspective of Board members and senior administra- elsewhere are facing significant resource allocation chal- tors themselves about what decision-making elements lenges. Priorities must be set among competing opportu- (criteria and processes) they would find most useful in set- nities because demand for health care exceeds available ting priorities or how they would evaluate the success of a resources. Board members and senior administrators are priority setting exercise. looking for practical ways to improve how they set priori- ties under resource constraints. The priority setting litera- Fairness is a key ethical goal of priority setting when ture describes priority setting in various health care health care resources are scarce. Experience shows that contexts [1-9]. It identifies a number of decision-making there is often disagreement on what principles should be principles and approaches that could be used to set prior- used to make fair allocation decisions (i.e., distributive Page 1 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 fairness) [8,17]. This means that decision-makers must ered to be the most relevant decision factors (or 'reasons') rely instead on a fair process (i.e., procedural fairness) to for setting clinical service priorities in their organisations. establish the legitimacy of priority setting decisions [16,18]. Norman Daniels and James Sabin have devel- 'Strategic fit' described the extent to which clinical services oped a fair process model for priority setting called contributed to advancing the strategic directions of the 'accountability for reasonableness' (A4R) [16]. Based on organisation, i.e., "fit" with the organization's vision, mis- justice theories of democratic deliberation, A4R identifies sion, values, and goals. This criterion was consistent with four conditions of a fair priority setting process (Table 1). the idea that strategy should be a key driver of operational We, and others, have been exploring the application of planning as a counterpoint to planning based on histori- A4R in various health care settings [19-23]. Our experi- cal or short-term political considerations. ence suggests that A4R can provide valuable practical guidance to improve the fairness of actual priority setting 'Alignment with external directives' identified existing in health care organizations and to enhance public government mandates and legislated obligations as rele- accountability for priority setting [9,23]. vant considerations for setting priorities. For example, each organisation had government directives to provide To assist decision-makers in developing fair priority set- particular health services at prescribed volumes. This ting processes, we conducted one-day workshops for criterion recognised explicitly the limited degrees of free- Board members and senior administrators at three Cana- dom within which priorities could be set, but also high- dian academic health science centres (Saskatoon Health lighted the importance for decision-makers of Region, Kingston General Hospital and The Ottawa Hos- participating with government in achieving regional and pital), who were seeking ethics advice on how to improve provincial health service objectives. priority setting in their organisations. Each organization was faced with setting priorities among their clinical serv- 'Academic commitments' consisted of two sub-criteria ices to guide resource allocation under significant budget reflective of each organization's close affiliation with a constraints. The goal of each workshop was to help deci- local university and medical school. The 'education' sub- sion-makers develop a strategy for fair priority setting criterion emphasised the role of clinical programs in edu- based on the conditions of A4R. Using case-based plenary cating future health care professionals and in facilitating sessions to introduce the key concepts (e.g., a case about the integration of these activities with health service deliv- how one organisation developed and used criteria to set ery. The 'research' sub-criterion emphasised the role of clinical service priorities illustrated the importance of pri- academic health science centres in establishing best prac- ority setting criteria for operationalising the Relevance tice standards, in generating new medical knowledge condition of A4R) and facilitating consensus through (including practice-based and bench research), and in small and large group discussions, we assisted workshop developing technological innovation. Workshop partici- participants in reaching agreement on: a) the criteria deci- pants felt that this criterion affirmed the unique role of sion-makers would use to set clinical service priorities, b) academic health science centres in advancing society's the processes they would follow, and c) the parameters health care knowledge and capacity. according to which they would evaluate the success of the priority setting exercise. 'Clinical impact' was defined primarily in terms of the service volumes necessary to ensure the clinical compe- We summarize key lessons learned from these workshops tence of medical staff to provide safe and effective care to to help decision-makers in other health care organizations patients. Other relevant factors included: evidence of develop their own fair priority setting strategies and to effectiveness in health promotion and disease prevention, improve understanding of researchers and policy makers uniqueness of the health service in the local area, and about priority setting from the point of view of decision- quality of the service provided. Workshop participants makers. expressed concern about their ability to measure clinical impact given the limitations of their institutional decision Discussion support capabilities (e.g., data, trained decision support Presentation of lessons learned staff). However, they felt that by identifying these factors, Priority setting criteria this could provide direction for the collection of appropri- When decision-makers were asked what criteria they ate data and information. would use to set clinical service priorities, we found that responses clustered around eight (8) criteria (Table 2). As 'Community need' described the health service needs of a step toward operationalising the Relevance condition of patients in the organisation's local catchment area. This A4R, these criteria describe what decision-makers consid- included current demand for health services, which could be measured on the basis of utilisation rates and waiting Page 2 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 Table 1: Accountability for reasonableness Relevance condition Decisions should be made on the basis of reasons (i.e., evidence, principles, arguments) that "fair-minded" people can agree are relevant under the circumstances. Publicity condition Decisions and their rationales should be transparent and made publicly accessible. Revision condition There should be opportunities to revisit and revise decisions in light of further evidence or arguments, and there should be a mechanism for challenge and dispute resolution. Enforcement condition There should be either voluntary or public regulation of the process to ensure that the other three conditions are met. Table 2: Priority setting criteria • Strategic fit • Alignment with external directives • Academic commitments – Education – Research • Clinical impact • Community needs • Partnerships (external) • Interdependency (internal) • Resource implications Table 3: Priority setting process elements • Confirm the strategic plan • Clarify programmatic architecture, including program groupings and definitions • Clarify Board/Mgmt roles and responsibilities • Determine who will make priority setting decisions and what they will do • Engage internal/external stakeholders • Define priority setting criteria and collect data/information • Develop an effective communication strategy • Develop a decision review process • Develop process monitoring and evaluation strategies • Support the process with leadership development and change management strategies list data, as well as future demand based on population quality and to optimise resource utilisation within the data and trends (e.g., aging population). Community region or local catchment area. need was further defined in terms of the availability of other health service providers. For example, community 'Interdependency' described the coordination and collab- need was seen to be greater if the organisation were the oration between clinical services within the organization sole provider of a health service to patients in the region to enhance service quality (e.g., through interdisciplinary than if there were other local providers whom patients models of care) or to use institutional resources more effi- might access for care. ciently. In the two organisations that had achieving a "healthy" workplace as a strategic goal, workshop partici- 'Partnerships' highlighted existing formal agreements and pants also related this criterion to quality of work life fac- commitments with other organisations in coordinating tors as key enablers of effective clinical coordination and delivery of health care to defined populations (e.g., refer- collaboration. ral agreements to ensure access to speciality care, or trans- fer agreements to coordinate the transition of patients 'Resource implications' included a cluster of factors from a hospital to a chronic continuing care facility). Part- related to the mobilisation and use of human and fiscal nerships were seen as effective ways to enhance service resources. Although recognising that strategic planning Page 3 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 should not be over-determined by operational issues, Workshop participants also identified a number of ele- workshop participants felt that the resource context was ments that were critical to the design of the priority setting relevant for setting clinical service priorities. For example, process itself: the implications of prioritisation depended in part on the source of funding (e.g., base hospital budget, ministry of (4) The executive decision-making group should be multi- health volume-based funding, donation), the availability disciplinary and its role should be clearly and explicitly of staff (e.g., nurses) and capital resources (e.g., equip- defined in advance of priority setting. Workshop partici- ment, space), the flexibility of contractual agreements pants emphasised the importance of shared accountabil- (e.g., union contracts), and the model of health service ity for priority setting across the clinical and delivery, which could be more or less efficient in using administrative leadership. Engaging the medical leader- available resources. ship in a decision-making role was identified as key to developing a successful priority setting process. The Priority setting processes engagement of other non-medical clinical leaders (e.g., When asked what key process elements would be needed nursing leadership) was also thought to be important for in order for priority setting to be accountable and fair, ensuring the legitimacy of the priority setting process. workshop participants identified ten (10) elements (Table 3). Some of these process elements reflected the Publicity, (5) Stakeholders should be engaged in the priority setting Revision, and Enforcement conditions of A4R. However, process. Although the organisational executive would ulti- decision-makers identified additional process considera- mately be accountable for making the priority setting tions that they felt were also essential for a successful pri- decisions, workshop participants felt that stakeholders ority setting process. could be engaged particularly as key informants through expert and broader stakeholder consultation. This consul- Workshop participants identified a number of prepara- tation should include both internal stakeholders (e.g., tory steps that should be taken before priority setting can staff, patient advisory groups) and external stakeholders begin: (e.g., institutional partners, community groups, govern- ment officials). (1) The organisation should establish, refine, or confirm its strategic plan. This is to ensure that the clinical service (6) Priority setting criteria should be clearly defined and priorities that emerge through the priority setting process understood by decision-makers and stakeholders. Data/ align with and advance the organisation's mission and information should be collected to support their applica- strategic goals. In effect, workshop participants felt that tion in the priority setting process. Workshop participants they needed to know first where the organisation was felt that the criteria identified in the workshop could be going so that they could set the right priorities for getting further refined through stakeholder engagement and there. tested with decision-makers to ensure a common interpre- tation of each criterion and consistency in their (2) The programmatic architecture of the organization implementation. (i.e., what services are offered and how they are grouped administratively and programmatically) should be clari- (7) An effective communication strategy should be devel- fied in order to set clinical service priorities relative to cur- oped to ensure a transparent priority setting process. The rent activities. This step was also felt to be important for purpose of the communication strategy should be to defining precisely what order of clinical service activity ensure that stakeholders know and understand the scope was to be prioritised and for creating an accurate inven- and necessity of priority setting decision-making, the tory of clinical services for prioritisation. degrees of freedom within which priority setting would take place (including explicit identification of any "sacred (3) The specific responsibilities of the Board and senior cows" that would be immune from priority setting), and management in relation to the priority setting process the particularities of the priority setting process (who will should be clarified explicitly and upfront. Decision-mak- do what, how the process will work, and why). In addi- ers identified some confusion about these responsibilities tion, the rationales for priority setting decisions should be given that clinical service priority setting involved an over- communicated to stakeholders and should clearly dem- lap of the strategic responsibility of the Board with the onstrate how these decisions are defensible in light of the operational responsibility of Senior Management. During priority setting criteria and available data/information. the workshop, Board members and Senior Managers drafted a memorandum of agreement delineating their (8) Decision review processes should be developed to respective roles and responsibilities in the priority setting incorporate opportunities to revisit and review decisions. process. Workshop participants saw these as additional Page 4 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 opportunities to engage stakeholders around difficult pri- enhancing the mission of the organization, in contribut- ority setting decisions, although they also expressed con- ing to conditions for growth, and in balancing the organ- cern that this might invite conflict between stakeholders izational budget. Effects on staff involved an evaluation of and decision-makers. However, it was generally felt that the impact of priority setting on staff satisfaction and this could be mitigated if decision review processes were morale, organizational recruitment and retention initia- focused explicitly on providing a vehicle for new data/ tives, and overall understanding of new priorities across information to be brought forward, material errors in the the organization. Effects on the community focused on original decision to be corrected based on available data/ how external stakeholders, including members of the information, and procedural inconsistencies to be public, regional partners, health care peers (e.g., other aca- addressed. demic health science organisations), and affiliated academic institutions, responded to the priority setting Workshop participants identified additional elements initiative. that were important to improve quality and strengthen capacity for fair priority setting in their organisations over Process parameters focused on the efficiency and fairness time: of the priority setting process. Efficiency of the priority set- ting process could be evaluated in terms of whether prior- (9) Process monitoring and formal evaluation strategies ity setting improved institutional capacity for allocating should be developed to ensure quality improvement and resources and making priority setting decisions, and to realise a commitment to organizational learning. whether stakeholders and decision-makers felt that the Workshop participants felt that the process should be priority setting process provided a worthwhile return on monitored for adherence to the conditions of A4R, thus the time invested to set priorities. Fairness of the priority allowing for mid-course corrections to enhance fairness as setting process could be evaluated in terms of whether the priority setting process unfolded. A formal evaluation stakeholders understood and felt engaged in the priority process after priority setting would allow institutional setting process, whether priority setting decisions were good practices as well as opportunities for improvement justified and seen to be reasonable, and whether 'winners' to be captured so that this information could lead to and 'losers' both felt that they had been fairly treated. improved priority setting in the future. For example, Mar- tin & Singer have developed an ethics-based quality It was interesting to us that, although A4R was presented improvement model that focuses on evaluating and as an ethical framework for fair priority setting, workshop improving the fairness of priority setting processes [23]. participants did not specifically identify conformity with its conditions as a parameter of success related to fairness. (10) The priority setting process should be supported by The importance of these conditions is clearly evident, leadership development and change management strate- however, among the fairness considerations they cited as gies to strengthen institutional capacity for priority setting well as the process elements they identified as key to set- decision-making. Capacity strengthening should focus in ting priorities. Moreover, we had been invited to work particular on middle managers, who may not be among with these executive teams precisely because they were the decision-making group but who would play key roles seeking an ethical framework through which to improve in communicating with staff and in implementing the pri- how they set priorities in their organisations. This suggests ority setting decisions. to us that A4R was seen by workshop participants prima- rily as an ethical framework for process design rather than Parameters of successful priority setting for the evaluation of priority setting processes ex post facto. When asked how they would know that the priority set- Implications of lessons learned ting process had been a success, workshop participants identified both outcome and process parameters (Table Our findings from these three priority setting workshops 4). In either case, key marks of its success were whether the illuminate the complex challenges faced by decision-mak- process were perceived to be an improvement over past ers in managing scarce health care resources. The range of priority setting initiatives and whether it were imple- criteria identified in the workshops provides insight into mented in subsequent iterations of priority setting. the competing goals (e.g., clinical vs. academic, local vs. systemic, strategic vs. operational) and multiple stake- Outcome parameters focused on the effects of priority set- holder relationships that decision-makers must consider ting on organizational priorities and budget, on staff, and in setting clinical service priorities. This is consistent with on the community. Effects on organizational priorities previous findings that efficiency considerations or simple and budget concerned the extent to which the priority set- technical solutions have only limited influence on deci- ting process was successful in changing organizational pri- sion-making and are not sufficient alone to guide priority orities and shifting resources, in supporting and/or setting decision-making [8,17,24,25]. Given the range of Page 5 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 Table 4: Parameters of success Outcome parameters Process parameters Effect on organizational priorities and budget Efficiency of priority setting process • Priorities change; resource shift • Increased ease in allocating resources • Strategic plan supported/enhanced • Improved capacity for making priority setting decisions • Conditions for growth created/enhanced • Perceived return on time invested • Budget balanced Effect on staff Fairness • Staff satisfaction neutral or positive • Stakeholders understand the process • Staff retention/recruitment neutral or positive • Stakeholders feel engaged • Organizational understanding improved • Priorities are justified and seen to be reasonable • Process is perceived to be consistent and fair • Winners/losers issue well-managed Effect on community Conformity with conditions of 'accountability for reasonableness'? • Public media recognition neutral or positive • Public acceptance or community support improved • Public perception of institutional accountability improved • Health care integration through partnerships increased • Education/research peer recognition enhanced • Emulated by other organizations interested stakeholders and competing values, our find- priority setting in various institutional settings ings underscore the importance of procedural fairness to [9,16,20,27]. Thus, decision-makers in other health care secure socially acceptable priority setting decisions and to organisations may draw lessons from these workshops to ensure public accountability [8,18,26]. This suggests that operationalise fair priority setting processes that reflect a fair process model like A4R may be particularly suitable the particularities of their institutional circumstances and to help decision-makers set legitimate and fair clinical ensure accountability for the reasonableness of their clin- service priorities. ical service priorities. Although we report only on three health care organiza- Our experience shows that, from the perspective of Board tions, the organisations were all academic health science members and senior leaders, our practical approach using centres facing similar resource challenges. Consensus A4R offers useful guidance for developing fair and pub- around priority setting criteria and processes emerged licly accountable priority setting processes under resource independently among workshop participants in their constraints. However, alternative priority setting large and small group discussions. However, this does not approaches may also be beneficial. For example, program mean that these findings are exhaustive of the priority set- budgeting and marginal analysis, an economics-based ting criteria that might be relevant for setting clinical serv- approach, has been used with senior health care adminis- ice priorities (e.g., in community hospitals without trators in Canada and elsewhere to improve how priority academic affiliations) or the process elements that would setting optimises health and non-health benefits within be necessary to ensure a legitimate and fair priority setting available resources [13]. A comparison of priority setting process. Moreover, although our approach was based on approaches has not been done, however preliminary work the notion that fair priority setting requires a normative has begun to explore a more interdisciplinary priority set- grounding in procedural justice – in this case, A4R – this ting approach (Gibson JL, Mitton C, Martin DK, Donald- does not mean that these findings are normatively 'right' son C, Singer PA, manuscript submitted) [21]. for clinical service priority setting in all health care organ- isations. An evaluation of the normative 'rightness' Despite these possible limitations, the lessons we report depends to some extent on the specific institutional cir- here fill an important gap in the literature about the crite- cumstances under which priority setting is taking place, ria, processes, and parameters of success decision-makers the stakeholders who are affected, and the strategic goals would use to set priorities using an ethical framework. We that are being pursued. Experience shows, moreover, that expect that decision-makers in other health care the conditions of A4R are sufficiently general to guide fair organizations may find themselves in the workshop par- Page 6 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 toral fellowship while writing this paper. Dr. Martin is supported by an ticipants' experience of priority setting and may use these Ontario Ministry of Health and Long-Term Care Career Scientist Award. findings as a basis for discussing how they could enhance Dr. Singer is supported by a Canadian Institutes of Health Research Distin- the fairness and public accountability of their own prior- guished Investigator award. This research was also supported by an Inter- ity setting processes. disciplinary Capacity Enhancement Grant from the Canadian Institutes of Health Research. Summary  Hospitals and regional health authorities must set prior- References ities in the face of resource constraints. 1. Mitton CR, Donaldson C: Setting priorities and allocating resources in health regions: lessons from a project evaluat- ing program budgeting and marginal analysis (PBMA). Health  Decision-makers seek pragmatic ways to set priorities Policy 2003, 64:335-348. fairly in strategic planning, but find limited guidance from 2. Kapiriri L, Norheim OF, Heggenhougen K: Using burden of dis- ease information for health planning in developing countries: the literature. the experience from Uganda. Social Science & Medicine 2003, 56:2433-2441. 3. PausJenssen A, Singer PA, Detsky AS: How Ontario's formulary  We facilitated workshops for board members and senior committee makes recommendations. Pharmacoeconomics 2003, leadership at three organizations to assist them in devel- 21:285-294. oping a strategy for fair priority setting. 4. Ham C, McIver S: Contested decisions: priority setting in the NHS London: King's Fund Publishing; 2000. 5. Foy R, So J, Rous E, Scarffe JH: Perspectives of commissioners  Workshop participants identified 8 priority setting crite- and cancer specialists in prioritizing new cancer drugs: impact of the evidence threshold. BMJ 1999, 318:456-459. ria, 10 key priority setting process elements, and 6 param- 6. Hope T, Hicks N, Reynolds DJM, Crisp R, Griffiths S: Rationing and eters of success that they would use to set priorities in their the health authority. BMJ 1998, 317:1067-1069. organizations. 7. Deber R, Wiktorowicz M, Leatt P, Champagne F: Technology acquisition in Canadian hospitals: How is it done, and where is the information coming from? Healthcare Management Forum  Decision-makers in other organizations can draw les- 1994, 7:18-27. sons from these findings to enhance the fairness of their 8. Holm S: Developments in Nordic countries – goodbye to the simple solutions. In The Global Challenge of Health Care Rationing priority setting decision-making. Edited by: Coulter A, Ham C. Buckingham: Open University Press; 2000:29-37. 9. Martin D, Shulman K, Santiago-Sorrell P, Singer P: Priority-setting Competing interests and hospital strategic planning: a qualitative case study. Jour- The authors were compensated by the health care organi- nal of Health Services Research and Policy 2003, 8(4):197-201. zations for facilitating the priority setting workshops and 10. Cookson R, Dolan P: Principles of justice in health care rationing. Journal of Medical Ethics 2000, 26:323-329. continue to consult with these and other health care 11. Emanuel EJ: Justice and managed care: four principles for the organizations. just allocation of health care resources. Hastings Center Report 2000, 30:8-16. 12. Mooney G: Vertical equity in health care resource allocation. Authors' contributions Health Care Analysis 2000, 8:203-215. JLG conducted the workshops on which this paper is 13. Mitton C, Donaldson C: Setting priorities and allocating resources in health regions: lessons from a project evaluat- based, collated and analysed the data, and drafted the ing program budgeting and marginal analysis (PMBA). Health manuscript. Policy 2003, 64:335-348. 14. Farrar S, Ryan M, Ross D, Ludbrook A: Using discrete choice modelling in priority setting: an application to clinical service DKM participated in analysing the data and commented developments. Social Science and Medicine 2000, 50:63-75. on earlier drafts of the manuscript. 15. Mullen PM: Public involvement in health care priority setting: are the methods appropriate and valid? In The global challenge of health care rationing Edited by: Coulter A, Ham C. Buckingham, UK: PAS conducted the workshops on which this paper is Open University Press; 2000:163-174. based, participated in analysing the data, commented on 16. Daniels N, Sabin JE: Setting limits fairly: Can we learn to share medical resources? Oxford: Oxford University Press; 2002. earlier drafts of the manuscript, and conceived of the 17. Daniels N: Four unsolved rationing problems: a challenge. paper. Hastings Center Report 1994, 24:27-29. 18. Klein R, William A: Setting priorities: what is holding us back – inadequate information or inadequate institutions? In The glo- All authors read and approved the final manuscript. bal challenge of health care rationing Edited by: Coulter A, Ham C. Buckingham, UK: Open University Press; 2000:15-26. 19. Singer PA, Martin DK, Giacomini M, Purdy L: Priority setting for Acknowledgments new technologies in medicine: a qualitative case study. BMJ We would like to acknowledge gratefully the senior leadership at the Sas- 2000, 321:1316-1318. katoon Health Region, the Kingston General Hospital and the Ottawa Hos- 20. Ham C: Tragic choices in health care: lessons from the Child pital who participated in the workshops and who have given us permission B case. BMJ 1999, 319:1258-1261. to share lessons learned from their workshops. 21. Mitton C, Donaldson C: Health care priority setting: principles, practice and challenge. Cost Effectiveness and Resource Allocation 2004, 2:3. Grant support: The views expressed herein are those of the authors and 22. Norheim O: Procedures for priority setting and mechanisms do not necessarily reflect those of the supporting groups. Dr. Gibson was of appeal in the Norwegian health care system. Presentation at supported by a Canadian Health Services Research Foundation post-doc- Page 7 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 the 3rd International Conference on Priorities in Health Care, Amsterdam 23. Martin D, Singer P: A strategy to improve priority setting in health care institutions. 2003, 11:59-68. 24. PausJenssen A, Singer PA, Detsky AS: How Ontario's formulary committee makes recommendations. Pharmacoeconomics 2003, 21:285-294. 25. Russel LB, Gold MR, Siegel JE, Daniels N, Weinstein MC, for the Panel on Cost-Effectiveness in Health and Medicine: Journal of the American Medical Association 1996, 276:1172-1177. 26. Jan S, Dommers E, Mooney G: A politico-economic analysis of decision-making in funding health service organisations. Social Science and Medicine 2003, 57:427-435. 27. Martin DK, Walton N, Singer PA: Priority setting in surgery: improve the process and share the learning. World Journal of Surgery 2003, 27:962-966. 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Setting priorities in health care organizations: criteria, processes, and parameters of success

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Springer Journals
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Copyright © 2004 by Gibson et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Management/Nursing Research
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1472-6963
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10.1186/1472-6963-4-25
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15355544
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Abstract

Background: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. Discussion: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. Summary: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly. Background ities [10-16]. However, very little has been reported from Hospitals and regional health authorities in Canada and the perspective of Board members and senior administra- elsewhere are facing significant resource allocation chal- tors themselves about what decision-making elements lenges. Priorities must be set among competing opportu- (criteria and processes) they would find most useful in set- nities because demand for health care exceeds available ting priorities or how they would evaluate the success of a resources. Board members and senior administrators are priority setting exercise. looking for practical ways to improve how they set priori- ties under resource constraints. The priority setting litera- Fairness is a key ethical goal of priority setting when ture describes priority setting in various health care health care resources are scarce. Experience shows that contexts [1-9]. It identifies a number of decision-making there is often disagreement on what principles should be principles and approaches that could be used to set prior- used to make fair allocation decisions (i.e., distributive Page 1 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 fairness) [8,17]. This means that decision-makers must ered to be the most relevant decision factors (or 'reasons') rely instead on a fair process (i.e., procedural fairness) to for setting clinical service priorities in their organisations. establish the legitimacy of priority setting decisions [16,18]. Norman Daniels and James Sabin have devel- 'Strategic fit' described the extent to which clinical services oped a fair process model for priority setting called contributed to advancing the strategic directions of the 'accountability for reasonableness' (A4R) [16]. Based on organisation, i.e., "fit" with the organization's vision, mis- justice theories of democratic deliberation, A4R identifies sion, values, and goals. This criterion was consistent with four conditions of a fair priority setting process (Table 1). the idea that strategy should be a key driver of operational We, and others, have been exploring the application of planning as a counterpoint to planning based on histori- A4R in various health care settings [19-23]. Our experi- cal or short-term political considerations. ence suggests that A4R can provide valuable practical guidance to improve the fairness of actual priority setting 'Alignment with external directives' identified existing in health care organizations and to enhance public government mandates and legislated obligations as rele- accountability for priority setting [9,23]. vant considerations for setting priorities. For example, each organisation had government directives to provide To assist decision-makers in developing fair priority set- particular health services at prescribed volumes. This ting processes, we conducted one-day workshops for criterion recognised explicitly the limited degrees of free- Board members and senior administrators at three Cana- dom within which priorities could be set, but also high- dian academic health science centres (Saskatoon Health lighted the importance for decision-makers of Region, Kingston General Hospital and The Ottawa Hos- participating with government in achieving regional and pital), who were seeking ethics advice on how to improve provincial health service objectives. priority setting in their organisations. Each organization was faced with setting priorities among their clinical serv- 'Academic commitments' consisted of two sub-criteria ices to guide resource allocation under significant budget reflective of each organization's close affiliation with a constraints. The goal of each workshop was to help deci- local university and medical school. The 'education' sub- sion-makers develop a strategy for fair priority setting criterion emphasised the role of clinical programs in edu- based on the conditions of A4R. Using case-based plenary cating future health care professionals and in facilitating sessions to introduce the key concepts (e.g., a case about the integration of these activities with health service deliv- how one organisation developed and used criteria to set ery. The 'research' sub-criterion emphasised the role of clinical service priorities illustrated the importance of pri- academic health science centres in establishing best prac- ority setting criteria for operationalising the Relevance tice standards, in generating new medical knowledge condition of A4R) and facilitating consensus through (including practice-based and bench research), and in small and large group discussions, we assisted workshop developing technological innovation. Workshop partici- participants in reaching agreement on: a) the criteria deci- pants felt that this criterion affirmed the unique role of sion-makers would use to set clinical service priorities, b) academic health science centres in advancing society's the processes they would follow, and c) the parameters health care knowledge and capacity. according to which they would evaluate the success of the priority setting exercise. 'Clinical impact' was defined primarily in terms of the service volumes necessary to ensure the clinical compe- We summarize key lessons learned from these workshops tence of medical staff to provide safe and effective care to to help decision-makers in other health care organizations patients. Other relevant factors included: evidence of develop their own fair priority setting strategies and to effectiveness in health promotion and disease prevention, improve understanding of researchers and policy makers uniqueness of the health service in the local area, and about priority setting from the point of view of decision- quality of the service provided. Workshop participants makers. expressed concern about their ability to measure clinical impact given the limitations of their institutional decision Discussion support capabilities (e.g., data, trained decision support Presentation of lessons learned staff). However, they felt that by identifying these factors, Priority setting criteria this could provide direction for the collection of appropri- When decision-makers were asked what criteria they ate data and information. would use to set clinical service priorities, we found that responses clustered around eight (8) criteria (Table 2). As 'Community need' described the health service needs of a step toward operationalising the Relevance condition of patients in the organisation's local catchment area. This A4R, these criteria describe what decision-makers consid- included current demand for health services, which could be measured on the basis of utilisation rates and waiting Page 2 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 Table 1: Accountability for reasonableness Relevance condition Decisions should be made on the basis of reasons (i.e., evidence, principles, arguments) that "fair-minded" people can agree are relevant under the circumstances. Publicity condition Decisions and their rationales should be transparent and made publicly accessible. Revision condition There should be opportunities to revisit and revise decisions in light of further evidence or arguments, and there should be a mechanism for challenge and dispute resolution. Enforcement condition There should be either voluntary or public regulation of the process to ensure that the other three conditions are met. Table 2: Priority setting criteria • Strategic fit • Alignment with external directives • Academic commitments – Education – Research • Clinical impact • Community needs • Partnerships (external) • Interdependency (internal) • Resource implications Table 3: Priority setting process elements • Confirm the strategic plan • Clarify programmatic architecture, including program groupings and definitions • Clarify Board/Mgmt roles and responsibilities • Determine who will make priority setting decisions and what they will do • Engage internal/external stakeholders • Define priority setting criteria and collect data/information • Develop an effective communication strategy • Develop a decision review process • Develop process monitoring and evaluation strategies • Support the process with leadership development and change management strategies list data, as well as future demand based on population quality and to optimise resource utilisation within the data and trends (e.g., aging population). Community region or local catchment area. need was further defined in terms of the availability of other health service providers. For example, community 'Interdependency' described the coordination and collab- need was seen to be greater if the organisation were the oration between clinical services within the organization sole provider of a health service to patients in the region to enhance service quality (e.g., through interdisciplinary than if there were other local providers whom patients models of care) or to use institutional resources more effi- might access for care. ciently. In the two organisations that had achieving a "healthy" workplace as a strategic goal, workshop partici- 'Partnerships' highlighted existing formal agreements and pants also related this criterion to quality of work life fac- commitments with other organisations in coordinating tors as key enablers of effective clinical coordination and delivery of health care to defined populations (e.g., refer- collaboration. ral agreements to ensure access to speciality care, or trans- fer agreements to coordinate the transition of patients 'Resource implications' included a cluster of factors from a hospital to a chronic continuing care facility). Part- related to the mobilisation and use of human and fiscal nerships were seen as effective ways to enhance service resources. Although recognising that strategic planning Page 3 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 should not be over-determined by operational issues, Workshop participants also identified a number of ele- workshop participants felt that the resource context was ments that were critical to the design of the priority setting relevant for setting clinical service priorities. For example, process itself: the implications of prioritisation depended in part on the source of funding (e.g., base hospital budget, ministry of (4) The executive decision-making group should be multi- health volume-based funding, donation), the availability disciplinary and its role should be clearly and explicitly of staff (e.g., nurses) and capital resources (e.g., equip- defined in advance of priority setting. Workshop partici- ment, space), the flexibility of contractual agreements pants emphasised the importance of shared accountabil- (e.g., union contracts), and the model of health service ity for priority setting across the clinical and delivery, which could be more or less efficient in using administrative leadership. Engaging the medical leader- available resources. ship in a decision-making role was identified as key to developing a successful priority setting process. The Priority setting processes engagement of other non-medical clinical leaders (e.g., When asked what key process elements would be needed nursing leadership) was also thought to be important for in order for priority setting to be accountable and fair, ensuring the legitimacy of the priority setting process. workshop participants identified ten (10) elements (Table 3). Some of these process elements reflected the Publicity, (5) Stakeholders should be engaged in the priority setting Revision, and Enforcement conditions of A4R. However, process. Although the organisational executive would ulti- decision-makers identified additional process considera- mately be accountable for making the priority setting tions that they felt were also essential for a successful pri- decisions, workshop participants felt that stakeholders ority setting process. could be engaged particularly as key informants through expert and broader stakeholder consultation. This consul- Workshop participants identified a number of prepara- tation should include both internal stakeholders (e.g., tory steps that should be taken before priority setting can staff, patient advisory groups) and external stakeholders begin: (e.g., institutional partners, community groups, govern- ment officials). (1) The organisation should establish, refine, or confirm its strategic plan. This is to ensure that the clinical service (6) Priority setting criteria should be clearly defined and priorities that emerge through the priority setting process understood by decision-makers and stakeholders. Data/ align with and advance the organisation's mission and information should be collected to support their applica- strategic goals. In effect, workshop participants felt that tion in the priority setting process. Workshop participants they needed to know first where the organisation was felt that the criteria identified in the workshop could be going so that they could set the right priorities for getting further refined through stakeholder engagement and there. tested with decision-makers to ensure a common interpre- tation of each criterion and consistency in their (2) The programmatic architecture of the organization implementation. (i.e., what services are offered and how they are grouped administratively and programmatically) should be clari- (7) An effective communication strategy should be devel- fied in order to set clinical service priorities relative to cur- oped to ensure a transparent priority setting process. The rent activities. This step was also felt to be important for purpose of the communication strategy should be to defining precisely what order of clinical service activity ensure that stakeholders know and understand the scope was to be prioritised and for creating an accurate inven- and necessity of priority setting decision-making, the tory of clinical services for prioritisation. degrees of freedom within which priority setting would take place (including explicit identification of any "sacred (3) The specific responsibilities of the Board and senior cows" that would be immune from priority setting), and management in relation to the priority setting process the particularities of the priority setting process (who will should be clarified explicitly and upfront. Decision-mak- do what, how the process will work, and why). In addi- ers identified some confusion about these responsibilities tion, the rationales for priority setting decisions should be given that clinical service priority setting involved an over- communicated to stakeholders and should clearly dem- lap of the strategic responsibility of the Board with the onstrate how these decisions are defensible in light of the operational responsibility of Senior Management. During priority setting criteria and available data/information. the workshop, Board members and Senior Managers drafted a memorandum of agreement delineating their (8) Decision review processes should be developed to respective roles and responsibilities in the priority setting incorporate opportunities to revisit and review decisions. process. Workshop participants saw these as additional Page 4 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 opportunities to engage stakeholders around difficult pri- enhancing the mission of the organization, in contribut- ority setting decisions, although they also expressed con- ing to conditions for growth, and in balancing the organ- cern that this might invite conflict between stakeholders izational budget. Effects on staff involved an evaluation of and decision-makers. However, it was generally felt that the impact of priority setting on staff satisfaction and this could be mitigated if decision review processes were morale, organizational recruitment and retention initia- focused explicitly on providing a vehicle for new data/ tives, and overall understanding of new priorities across information to be brought forward, material errors in the the organization. Effects on the community focused on original decision to be corrected based on available data/ how external stakeholders, including members of the information, and procedural inconsistencies to be public, regional partners, health care peers (e.g., other aca- addressed. demic health science organisations), and affiliated academic institutions, responded to the priority setting Workshop participants identified additional elements initiative. that were important to improve quality and strengthen capacity for fair priority setting in their organisations over Process parameters focused on the efficiency and fairness time: of the priority setting process. Efficiency of the priority set- ting process could be evaluated in terms of whether prior- (9) Process monitoring and formal evaluation strategies ity setting improved institutional capacity for allocating should be developed to ensure quality improvement and resources and making priority setting decisions, and to realise a commitment to organizational learning. whether stakeholders and decision-makers felt that the Workshop participants felt that the process should be priority setting process provided a worthwhile return on monitored for adherence to the conditions of A4R, thus the time invested to set priorities. Fairness of the priority allowing for mid-course corrections to enhance fairness as setting process could be evaluated in terms of whether the priority setting process unfolded. A formal evaluation stakeholders understood and felt engaged in the priority process after priority setting would allow institutional setting process, whether priority setting decisions were good practices as well as opportunities for improvement justified and seen to be reasonable, and whether 'winners' to be captured so that this information could lead to and 'losers' both felt that they had been fairly treated. improved priority setting in the future. For example, Mar- tin & Singer have developed an ethics-based quality It was interesting to us that, although A4R was presented improvement model that focuses on evaluating and as an ethical framework for fair priority setting, workshop improving the fairness of priority setting processes [23]. participants did not specifically identify conformity with its conditions as a parameter of success related to fairness. (10) The priority setting process should be supported by The importance of these conditions is clearly evident, leadership development and change management strate- however, among the fairness considerations they cited as gies to strengthen institutional capacity for priority setting well as the process elements they identified as key to set- decision-making. Capacity strengthening should focus in ting priorities. Moreover, we had been invited to work particular on middle managers, who may not be among with these executive teams precisely because they were the decision-making group but who would play key roles seeking an ethical framework through which to improve in communicating with staff and in implementing the pri- how they set priorities in their organisations. This suggests ority setting decisions. to us that A4R was seen by workshop participants prima- rily as an ethical framework for process design rather than Parameters of successful priority setting for the evaluation of priority setting processes ex post facto. When asked how they would know that the priority set- Implications of lessons learned ting process had been a success, workshop participants identified both outcome and process parameters (Table Our findings from these three priority setting workshops 4). In either case, key marks of its success were whether the illuminate the complex challenges faced by decision-mak- process were perceived to be an improvement over past ers in managing scarce health care resources. The range of priority setting initiatives and whether it were imple- criteria identified in the workshops provides insight into mented in subsequent iterations of priority setting. the competing goals (e.g., clinical vs. academic, local vs. systemic, strategic vs. operational) and multiple stake- Outcome parameters focused on the effects of priority set- holder relationships that decision-makers must consider ting on organizational priorities and budget, on staff, and in setting clinical service priorities. This is consistent with on the community. Effects on organizational priorities previous findings that efficiency considerations or simple and budget concerned the extent to which the priority set- technical solutions have only limited influence on deci- ting process was successful in changing organizational pri- sion-making and are not sufficient alone to guide priority orities and shifting resources, in supporting and/or setting decision-making [8,17,24,25]. Given the range of Page 5 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 Table 4: Parameters of success Outcome parameters Process parameters Effect on organizational priorities and budget Efficiency of priority setting process • Priorities change; resource shift • Increased ease in allocating resources • Strategic plan supported/enhanced • Improved capacity for making priority setting decisions • Conditions for growth created/enhanced • Perceived return on time invested • Budget balanced Effect on staff Fairness • Staff satisfaction neutral or positive • Stakeholders understand the process • Staff retention/recruitment neutral or positive • Stakeholders feel engaged • Organizational understanding improved • Priorities are justified and seen to be reasonable • Process is perceived to be consistent and fair • Winners/losers issue well-managed Effect on community Conformity with conditions of 'accountability for reasonableness'? • Public media recognition neutral or positive • Public acceptance or community support improved • Public perception of institutional accountability improved • Health care integration through partnerships increased • Education/research peer recognition enhanced • Emulated by other organizations interested stakeholders and competing values, our find- priority setting in various institutional settings ings underscore the importance of procedural fairness to [9,16,20,27]. Thus, decision-makers in other health care secure socially acceptable priority setting decisions and to organisations may draw lessons from these workshops to ensure public accountability [8,18,26]. This suggests that operationalise fair priority setting processes that reflect a fair process model like A4R may be particularly suitable the particularities of their institutional circumstances and to help decision-makers set legitimate and fair clinical ensure accountability for the reasonableness of their clin- service priorities. ical service priorities. Although we report only on three health care organiza- Our experience shows that, from the perspective of Board tions, the organisations were all academic health science members and senior leaders, our practical approach using centres facing similar resource challenges. Consensus A4R offers useful guidance for developing fair and pub- around priority setting criteria and processes emerged licly accountable priority setting processes under resource independently among workshop participants in their constraints. However, alternative priority setting large and small group discussions. However, this does not approaches may also be beneficial. For example, program mean that these findings are exhaustive of the priority set- budgeting and marginal analysis, an economics-based ting criteria that might be relevant for setting clinical serv- approach, has been used with senior health care adminis- ice priorities (e.g., in community hospitals without trators in Canada and elsewhere to improve how priority academic affiliations) or the process elements that would setting optimises health and non-health benefits within be necessary to ensure a legitimate and fair priority setting available resources [13]. A comparison of priority setting process. Moreover, although our approach was based on approaches has not been done, however preliminary work the notion that fair priority setting requires a normative has begun to explore a more interdisciplinary priority set- grounding in procedural justice – in this case, A4R – this ting approach (Gibson JL, Mitton C, Martin DK, Donald- does not mean that these findings are normatively 'right' son C, Singer PA, manuscript submitted) [21]. for clinical service priority setting in all health care organ- isations. An evaluation of the normative 'rightness' Despite these possible limitations, the lessons we report depends to some extent on the specific institutional cir- here fill an important gap in the literature about the crite- cumstances under which priority setting is taking place, ria, processes, and parameters of success decision-makers the stakeholders who are affected, and the strategic goals would use to set priorities using an ethical framework. We that are being pursued. Experience shows, moreover, that expect that decision-makers in other health care the conditions of A4R are sufficiently general to guide fair organizations may find themselves in the workshop par- Page 6 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 toral fellowship while writing this paper. Dr. Martin is supported by an ticipants' experience of priority setting and may use these Ontario Ministry of Health and Long-Term Care Career Scientist Award. findings as a basis for discussing how they could enhance Dr. Singer is supported by a Canadian Institutes of Health Research Distin- the fairness and public accountability of their own prior- guished Investigator award. This research was also supported by an Inter- ity setting processes. disciplinary Capacity Enhancement Grant from the Canadian Institutes of Health Research. Summary  Hospitals and regional health authorities must set prior- References ities in the face of resource constraints. 1. Mitton CR, Donaldson C: Setting priorities and allocating resources in health regions: lessons from a project evaluat- ing program budgeting and marginal analysis (PBMA). Health  Decision-makers seek pragmatic ways to set priorities Policy 2003, 64:335-348. fairly in strategic planning, but find limited guidance from 2. Kapiriri L, Norheim OF, Heggenhougen K: Using burden of dis- ease information for health planning in developing countries: the literature. the experience from Uganda. Social Science & Medicine 2003, 56:2433-2441. 3. PausJenssen A, Singer PA, Detsky AS: How Ontario's formulary  We facilitated workshops for board members and senior committee makes recommendations. Pharmacoeconomics 2003, leadership at three organizations to assist them in devel- 21:285-294. oping a strategy for fair priority setting. 4. 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JLG conducted the workshops on which this paper is 13. Mitton C, Donaldson C: Setting priorities and allocating resources in health regions: lessons from a project evaluat- based, collated and analysed the data, and drafted the ing program budgeting and marginal analysis (PMBA). Health manuscript. Policy 2003, 64:335-348. 14. Farrar S, Ryan M, Ross D, Ludbrook A: Using discrete choice modelling in priority setting: an application to clinical service DKM participated in analysing the data and commented developments. Social Science and Medicine 2000, 50:63-75. on earlier drafts of the manuscript. 15. Mullen PM: Public involvement in health care priority setting: are the methods appropriate and valid? In The global challenge of health care rationing Edited by: Coulter A, Ham C. Buckingham, UK: PAS conducted the workshops on which this paper is Open University Press; 2000:163-174. based, participated in analysing the data, commented on 16. Daniels N, Sabin JE: Setting limits fairly: Can we learn to share medical resources? Oxford: Oxford University Press; 2002. earlier drafts of the manuscript, and conceived of the 17. Daniels N: Four unsolved rationing problems: a challenge. paper. Hastings Center Report 1994, 24:27-29. 18. Klein R, William A: Setting priorities: what is holding us back – inadequate information or inadequate institutions? In The glo- All authors read and approved the final manuscript. bal challenge of health care rationing Edited by: Coulter A, Ham C. Buckingham, UK: Open University Press; 2000:15-26. 19. Singer PA, Martin DK, Giacomini M, Purdy L: Priority setting for Acknowledgments new technologies in medicine: a qualitative case study. BMJ We would like to acknowledge gratefully the senior leadership at the Sas- 2000, 321:1316-1318. katoon Health Region, the Kingston General Hospital and the Ottawa Hos- 20. Ham C: Tragic choices in health care: lessons from the Child pital who participated in the workshops and who have given us permission B case. BMJ 1999, 319:1258-1261. to share lessons learned from their workshops. 21. Mitton C, Donaldson C: Health care priority setting: principles, practice and challenge. Cost Effectiveness and Resource Allocation 2004, 2:3. Grant support: The views expressed herein are those of the authors and 22. Norheim O: Procedures for priority setting and mechanisms do not necessarily reflect those of the supporting groups. Dr. Gibson was of appeal in the Norwegian health care system. Presentation at supported by a Canadian Health Services Research Foundation post-doc- Page 7 of 8 (page number not for citation purposes) BMC Health Services Research 2004, 4:25 http://www.biomedcentral.com/1472-6963/4/25 the 3rd International Conference on Priorities in Health Care, Amsterdam 23. Martin D, Singer P: A strategy to improve priority setting in health care institutions. 2003, 11:59-68. 24. PausJenssen A, Singer PA, Detsky AS: How Ontario's formulary committee makes recommendations. Pharmacoeconomics 2003, 21:285-294. 25. Russel LB, Gold MR, Siegel JE, Daniels N, Weinstein MC, for the Panel on Cost-Effectiveness in Health and Medicine: Journal of the American Medical Association 1996, 276:1172-1177. 26. Jan S, Dommers E, Mooney G: A politico-economic analysis of decision-making in funding health service organisations. Social Science and Medicine 2003, 57:427-435. 27. Martin DK, Walton N, Singer PA: Priority setting in surgery: improve the process and share the learning. World Journal of Surgery 2003, 27:962-966. 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