Criteria-based resource allocation: A tool to improve public health impact
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1 Criteria-based resource allocation: A tool to improve public health impact Dr. Christopher Mackie Medical Officer of Health &CEO, Middlesex-London Health Unit Dinah Robinson Business Administrator, Ottawa Public Health
2 CFPC Conflict of Interest Disclosure of Commercial Support Presenter Disclosure Presenter: Gates Christopher Mackie, Dinah Robinson, Ross Graham, Katie Jackson, Shani Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None
3 MLHU Process Overview, Results & Considerations 3
4 4 The Challenge
5 5
6 6
7 7
8 The PricewaterhouseCoopers Review 8
9 What needs to change? Issue Impact Change Req d Link to Strategy Current process for costshared budget is driven primarily by external budget processes. The Board of Health s strategic priorities and operational input from the Service Areas are not well linked to the budget. The organization lacks a formal approach to seek the Board of Health s strategic and operational input early on in the budget process. As a result, the budget is not fully informed by strategic and operational needs. The budget process needs to start with strategic and operational planning to ensure that the budget is fully informed by strategic and operational requirements. Current Budget Process Uncertainty Both the timing and amount of funding are highly uncertain. More than 50% of the funding amount remains uncertain as late as Q3 of the operating year. Timing of approval of funding, particularly for 100% grants, is also difficult to predict. Service Areas face challenges in optimizing operating plans due to the uncertainty in the timing and amount of the funding. Service Areas need to be provided with guidance around strategic priorities and planning assumptions, well ahead of the budget cycle. The budget process needs to account for lack of certainty over the timing and amount of funding. Rigidity The budget process is a once-a-year event: once it is approved, there is little opportunity for the Board of Health to formally revise the agency budget. The Board of Health lacks a formal mechanism to refine the budget as new information becomes available, and can feel disconnected with the implementation of the budget. The budget process needs more frequent updates so that Service Areas can seek Board of Health input more quickly and flexibly to react to new information 9
10 Future budget/planning process attributes The future budget/planning process should better integrate operational planning with budget planning The future state process should be: Once implemented, MLHU should be able to: Adaptable Manageable Easily Understood Aligned with Board of Health s strategy Driven by program requirements Transparent Trustworthy 'Don't tell me what you value, show me your budget, and I'll tell you what you value. 10 Joe Biden Better align the budget to the Board of Health s overall strategic priorities Use operational plans to inform the development of the budget (not vice versa) Uphold public accountability over the use of financial resources in an open and transparent manner Foster confidence and trust in the integrity of the budget process Clearly communicate and report on the status of the budget, frequently and regularly, in order to facilitate effective decision making Manage the budget process more efficiently, spending less effort to achieve greater output React flexibly to new information and adapt the budget to ongoing developments
11 11 Management s Response
12 Changes to Planning/Budget Process 1. Support Informed Decision-Making: More detailed and relevant financial and program information 2. Enhance Transparency: Explicit criteria to guide development and selection of budget proposals 3. Ensure Value: Options from all service areas for reallocation of resources to ensure greatest impact on health across the Health Unit 4. Finance and Facilities Committee 12
13 13
14 14
15 PBMA Assumption: all of our programs and activities are valuable. Questions: 1. If we had the opportunity to invest, where would we do so in order to have the greatest impact? 2. If we had to disinvest, where would we do so in order to have the smallest reduction in impact? 3. Would we have a greater overall impact as an organization if we took some resources from 2 and put them in 1? 15
16 16 Diminishing Returns
17 Basic PBMA Process 1. Decide on roles & reallocation amount (MLHU s = 5%) 2. Develop criteria and weightings 3. Prepare software 4. Train/engage managers (rationale, software, budgets, process, etc.) 5. Engage staff 6. Develop & submit proposals 7. Review & select proposals for implementation 8. Appeal process 9. Recommend proposals to the Board 17
18
19 This is not about layoffs 19
20 20
21 21 Results
22 PBMA Criteria 1. Legislative Compliance (and Sector Alignment) 2. Health Need (Burden of Illness & SDOH) 3. Impact (Burden of Illness, SDOH, Client Service) 4. Community Capacity (Duplication vs. Our Niche) 5. Collaboration / Partnership (Maximizing impact over the long term) 6. Organizational Risks / Benefits (Reputation, Staff, Culture) 22
23 Results: Proposals 2014 Initiated (by managers): 116 Submitted (by directors): 96 Selected (by the Senior Leadership Team): disinvestments = $927K 18 investments = $818K 8 one-time investments = $343K Approved (by Board of Health): 60 (100%) 2015 Initiated (by managers): 116 Submitted (by directors): 69 Selected (by the Senior Leadership Team): disinvestments = $755K 18 investments = $717K + 9 one-time investments = $267K Approved (by Board of Health): 50 (100%) 23
24 Notable Disinvestments 2015
25 Infantline $58,888 disinvestment The MOHLTC Healthy Kids Initiative implemented a 24/7 provincial telephone line to assist mothers with breastfeeding and infant issues Overlap in service meant that resource could be reallocated to other programs
26 Ultra-Low Risk Food Premises Inspections $22,920 disinvestment Transition from active enforcement to complaints-based enforcement Continue to maintain inventory of premises and ensure they remain low-risk
27 Classroom-based Dental Health Education Lessons $64,000 disinvestment Transition from universal to targeted dental education lessons Fanshawe College students to provide this service in low-risk settings Enhanced with the delivery of fluoride varnish treatment
28 Notable Investments 2015
29 Community Drug $37,800 investment Strategy Lead Development and implementation of a Community Drug Strategy Based on Four Pillars Drug Strategy
30 Prenatal Care Program for Vulnerable Clients $50,000 investment Target prenatal information and education for vulnerable populations Includes skill building in the areas of healthy eating, physical activity and infant and child care
31 Climate Change Adaptation Campaign $66,765 one-time investment Delivery of a climate change adaptation education and outreach program Enables the community to be more adaptive and prepared for climate change
32 Reaction from Board Members As someone who is new to budget process, it's very accessible. I wish more public organizations budgeted this way. budget process is excellent. Check out the draft budgets for a few of its service areas #ldnont 32
33 It is our choices that show what we truly are, far more than our abilities. J.K Rowling
34 The measure of who we are is what we do with what we have. Vince Lombardi
35 Process Facilitators Staff identified as process manager Prioritize software Manager training Implemented as part of broader strategy (including new Board finance committee) Craig Mitton present during proposal selection meeting 35
36 Process Challenges Condensed timeline New concept Some staff disliked process (but overall, was well received) Focus on greater good mindset helped mitigate this No appeal process, open budget review meeting or public involvement (all part of normal process) Identifying which teams are included/excluded e.g. how to handle 100% funded* programs 36
37 Final Thoughts/Discussion Craig Mitton & Francois Dione are great resources PBMA process needs to be managed carefully, but much better than status quo Objective criteria take some effort to develop, but are worthwhile Integrating evidence Thank you 37
38 PBMA: The Ottawa Experience TOPHC 2015 Dinah Robinson, Ottawa Public Health, Business Administrator March 26, 2015
39 Why PBMA? Looking for transformational changes Challenged with prioritizing what to stop doing in order to invest in new initiatives Recognized the need to capture innovative ideas from more sources Greater engagement of frontline staff Timing: PBMA presentation at AOPHBA conference in Sept 2014 Opportunity to address 2015 budget challenges and Long Range Financial Plan 39
40 PBMA Process in Ottawa: Process Initiation Establish Project Scope Identify Targets for Investment & Disinvestment Develop Criteria, Weightings & Risks 40
41 Ottawa Evaluation Criteria 1. Health of the population (21) 2. Client experience / satisfaction (17) 3. Legislative requirement / alignment with Board direction (17) 4. OPH Workplace environment (5) 5. Equity (5) 6. Innovation and knowledge transfer (5) 7. Organizational status (10) 8. Partnerships (10) 9. Implementation challenges (5) 10.Funding source and degree of uncertainty of the financial impact (5) 4 1
42 PBMA Process in Ottawa: Identify & Evaluate Options Call for ideas Screening to identify synergies and options for proposal dev t Full proposal dev t within Prioritize Software and ranking Advisory Panel review of proposals and rankings 42
43 Family Health Pilot Results 109 ideas 20 proposals 7 recommendations 4 projects approved for implementation 43
44 Cross Program Discussions Make a Difference 44
45 PBMA Process in Ottawa: recommendations & approvals Recommendations to MOH and Board Communicate Decisions Implement Proposals Evaluate & Evolve Process 45
46 Resource Allocation Decisions Proposal Type Value ($K) Redesigning the Baby Express Refocus Telephone Postpartum Contact Transformation of School Health Alternate Delivery Models & Community Capacity Building Disinvestment 200 Disinvestment 200 Disinvestment 475 Investment 75 $800K net savings achieved 46
47 Family Health Pilot Outcomes Real resource shifts that are consistent with strategic priorities Greater engagement of frontline staff and supervisors An explicit and transparent process for program budgeting decisions Evidence driven decisions using consistent and explicit criteria Greater relevant communication Accreditation recommendation met Recommendations for action plans delivered 47
48 Lessons Learned Knowledgeable Advisory Panel members Criteria development process Communication value throughout entire process Leadership support Project team support Need time to: Synthesize ideas Discuss synergies between proposals Develop strong proposals 48
49 2015 Budget In the News... 49
50 2015 Budget In the News... 50
51 In the News... 51
52 OPH Launches Parenting Portal
53 OPH Launches Parenting Portal 53
54 New Expanded 2015 Approach Introduction of PBMA across entire all program areas Separate panel for each program standard Integration of strategic, operational and budget planning processes Continue work with Prioritize Consulting to evolve the software tool Communications remain key to successful project implementation 54
55 Group Work Review the scenario Select a scribe/speaker Discuss & respond to the questions
56 Scenario A: The Controversial Decision A disinvestment proposal to eliminate two half-time receptionist positions has been submitted. These positions are located at your health unit s smallest rural site, where a small number of programs and services are offered. Through, PBMA it is clear that resources allocated to these positions could have higher impact elsewhere. However, at the appeal stage, the proposal is highly controversial. Those in favour of eliminating the positions report the resources should be disinvested because the work previously done by these receptionists can be effectively reallocated. Those against eliminating the positions are concerned that losing reception services would affect operations, and that losing a human face at this site would make the site less attractive to clients and threaten its long-term viability. 1. How would you respond? 2. How would you address the concerns of both sides? 3. How would you resolve the issue?
57 Scenario B: Responding to Increasing Demands For the 2015 Accountability Agreement indicators, the Ministry has reintroduced 3 indicators related to school-aged vaccine coverage: % completed immunizations for Hep B, HPV & meningococcus. You have been assigned the task of ensuring your health unit is able to report on these 3 indicators throughout In the past, your health unit has struggled to track immunization rates for school-aged children, and despite the new Panorama system, you suspect that this will require additional resources, which your health unit does not have. How could PBMA be used to decide if more resources should be invested in this program area? 1. How would you start this discussion at your health unit? 2. Who would be the key stakeholders to engage? 3. What do you think the greatest challenges would be?
58 Questions? Thank you!
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