Table 2 Description of Elements in the Conceptual Framework

PROCESS CONCEPTS

1. Stakeholder Engagement

Stakeholder engagement refers to an organization's efforts to identify the relevant internal and external stakeholders and to involve those stakeholders effectively in the decision-making process. This should include, at a minimum, administrators, clinicians, members of the public and patients. To ensure adequate engagement, identifying and engaging stakeholders should involve multiple techniques, such as round tables, open forums, departmental meetings. There should be a genuine commitment from the organization to engage stakeholders effectively through partnership and empowerment. Stakeholder engagement is also concerned with stakeholder satisfaction regarding the level of their involvement in the decision-making process.

2. Explicit Process

An explicit process is one that is transparent, not only to decision makers, but also to other stakeholders. Adhering to a predetermined process can enhance trust and confidence in the process. Transparency means knowing who is making the decision as well as how and why the decision will be made. Communication needs to be well coordinated, systematic and well-planned. All stakeholders (internal and external) should be probed for information relevant to the priority setting decisions, and information should be communicated effectively using multiple vehicles (town-hall, departmental meetings, memos, emails, etc.)

3. Clear and Transparent Information Management

Information management refers first to the information made available to decision makers during the priority setting process. This includes what was used and what was perceived to be lacking. Second, information management considers how the information was managed, including how it was collected and collated. Relevant information includes, but is not restricted to: health outcomes data, economic data (such as cost effectiveness analyses), community needs assessment, current policies or policy reports, and the experiences of both clinicians and patients.

4. Consideration of Values and Context

Values and context are important considerations in any priority setting process, including the values of the organization, the values of staff within that organization, and the values of other stakeholders (such as patients, policy makers, politicians, and members of the community). The mission, vision and values of the organization should guide priority setting. Priority setting decisions should be based on reasons that are grounded in clear value choices, and those reasons should be made explicit. This also involves not only looking within the organization at previous priority setting decisions, but also studying what other health care organizations are doing. This would involve looking at organizations in the local community, at other health care organizations with similar mandates, as well as looking at the other levels of health care provision. Context is distinct from values and considers the organization's goals in the health care environment, as articulated in its strategic directions.

5. Revision or Appeals Mechanism

A revision process is a formal mechanism for the review of decisions, and for addressing disagreements constructively. Such a mechanism is important to ensure the priority setting process rules and requirements are communicated clearly ahead of time. The dual purposes of a revision process are to: 1) improve the quality of decisions by providing opportunities for new information to be brought forward, errors to be corrected, and failures in due process to be remedied; and 2) to operationalize the key ethical concept of responsiveness.

OUTCOME CONCEPTS

1. Stakeholder Understanding

Stakeholder understanding implies more than basic knowledge of the process. It assumes stakeholders have gained insight into the priority setting process (e.g., its goals, rationale and rationale for its decisions) and/or the organization (e.g., mission, vision, values, and strategic plan). As stakeholder understanding increases, stakeholder acceptance and confidence should also increase.

2. Shifted Resources

A successful priority setting process results in the allocation of budgets across portfolios, changes in utilization of physical resources (e.g., operating theatre schedules, bed allocations) or possibly changes in strategic directions. Effort that does not result in change may encourage the perception among stakeholders that the process is an inefficient use of time or is done for the outward appearance ('window-dressing') of pre-determined outcomes. A reaffirmation of previous resource allocation decisions (e.g. the previous year's budget) may, in some circumstances, be seen as a success.

3. Decision Making Quality

Decision making quality relates to appropriate use of available evidence, consistency of reasoning, institutionalization of the priority setting process, alignment with the goals of the process, and compliance with the prescribed process. It also captures the extent to which the institution is learning from its experience in order to facilitate ongoing improvement. This component is most visible as subsequent iterations of priority setting are evaluated; where consistency and building on previous priority setting would be indicative of a successful process. Institutional learning, increased institutionalization of priorities, more efficient decision making, more consistent decision making, and increased compliance with decisions (i.e. 'buy-in') are all valuable outcomes of successful priority setting that are difficult to achieve. Institutional learning from experience facilitates ongoing institutional improvement, which is made more visible as subsequent iterations of priority setting are evaluated.

4. Stakeholder Acceptance and Satisfaction

It is important to consider the satisfaction of all stakeholder groups, both internal and external to the hospital (community groups/public and governmental health agencies/ministries of health). Successful priority setting leads to increased satisfaction over multiple decision cycles. Stakeholder acceptance is indicated by continued willingness to participate in the process (i.e. 'buy-in') as well as the degree of contentment with the process. Stakeholders may be able to accept priority setting decisions, even if they may not always agree with the outcomes.

5. Positive Externalities

Positive externalities can act as a sort of check and balance, ensuring information is made transparent to stakeholders through various avenues, and/or establishing good practices for budgeting in other health care organizations. As an indicator of success, externalities may include positive media coverage (which can contribute to public dialogue, social learning, and improved decision making in subsequent iterations of priority setting), peer-emulation or health sector recognition (e.g. by other health care organizations, CCHSA, etc), changes in policies, and, potentially, changes to legislations or practice.