Implementing a rational priority setting approach in community care in the Interior Health Authority: assessing fit, evaluating implementation, and determining impact

Background: Priority setting approaches assist decision makers in choosing between various resource demands. One approach, Program Budgeting and Marginal Analysis (PBMA), supports decision makers to explicitly assess how resources can be used to maximize overall benefit from diverse service delivery options. Previous PBMA work establishes its efficacy (i.e., it can work) and also indicates that contextual factors complicate priority setting which can hamper PBMA effectiveness (i.e., whether it does actually work) in some settings. Methods: Using action research, researchers supported decision makers with implementing PBMA in a community care portfolio. Data were collected through semi-structured participant interviews (twenty pre-PBMA; twelve post year-1; nine post year-2), a pre-PBMA focus group (n=4), meeting attendance over three years, and document review. The interviews and focus group were transcribed. Data were analyzed using a constant comparison technique to explore PBMA effectiveness and implementation. Results: Fit emerged as a key theme in determining PBMA adoption and effectiveness. Here, fit refers to being of suitable quality and form to meet the end-users’ intended purposes and needs, and includes desirability, acceptability, and usability dimensions. Results confirm decision maker desire for rational approaches like PBMA. However, for several contextual reasons, most participants indicated that the timing and form in which PBMA was applied were not well-suited for this study. Their degree of acceptance of and buy-in to PBMA changed during the study: a leadership change, limited organizational commitment, and concerns with organizational capacity were key barriers to PBMA adoption. We found that adoption depended on contextual readiness and capacity, and that initial PBMA goals should include ensuring high-level commitment and moving toward more rational and evidence-informed decision making in general. Conclusions: These findings suggest that adding a contextual readiness/capacity assessment stage to PBMA, recognizing organizational complexity, and considering incremental PBMA adoption may help to improve PBMA’s effectiveness in some contexts. Based on these findings, tactics are suggested to more closely align PBMA with real-world priority setting practice. These suggestions may facilitate greater adoption, especially in contexts experiencing difficulty implementing PBMA. These insights may help in better understanding and working with priority setting conditions to advance evidence-informed decision making.Graduate Studies, College of (Okanagan)Graduat