ACHI Audio Conference Priority Setting for Community Benefit Melissa Biel, RN, DPA Biel Consulting July 9, 2009

Session Objectives  Discuss the process of selection of community programs based on community health needs.  Understand and apply a variety of methods for setting community benefit priorities based on identified community needs.

Community Benefit CHA/VHA Definition  Encompasses a full range of services and activities provided by nonprofit hospitals to address the symptoms and causes of health-related concerns.  A planned, managed and measured approach to meeting identified community health needs.  Implies collaboration with the community to benefit residents by improving health and quality of life.

Community Needs Resources Financial – Staff – Time

Community Benefit Goal (ASACB – To make optimal use of limited charitable resources to address unmet health-related needs.

C ommunity Benefit Planning and Implementation  Reduce health disparities  Reduce health care costs  Enhance community problem solving capacity

From Assessment to Plan  Needs Assessment  Priorities  Programs  Community Benefit Plan

Needs Assessment  Communities with DUHN (disproportionate unmet health need) are identified and documented in the community needs assessment.  Show evidence of high prevalence or severity of health concerns.  Identify geographic areas where residents are faced with multiple health problems and have limited access to health care.

From Assessment to Plan  Needs Assessment  Priorities  Programs  Community Benefit Plan

Priorities (1)  Priority setting for the selection of program content areas is one of the most important steps in the community assessment process, and one of the most neglected.  Establish explicit criteria and process used by community benefit committee and staff to select priority program areas of focus.

Priorities (2)  Most high quality community assessments produce a relatively large number of health concerns that could be viewed as important, if not priorities.  A more rational, deliberate, and evidence-based approach is needed.

Priorities (3)  The selection of priorities can be driven by factors ranging from who advocates most vigorously, or which stakeholders have more influence and resources to invest.  This approach yields priorities, but they may not represent the most effective use of limited resources.

Priorities (4) Priority setting should be based upon:  a clearly articulated set of criteria  areas where the needs are greatest  where the potential for producing measurable outcomes is highest  where community partners are most invested in positive results

Criteria and Process for Priority Setting  Develop a formal process and use explicit criteria to select program priorities.  The process should include diverse community stakeholders, who should play a significant role in determining the selection criteria.  Document the rationale for not addressing significant health issues identified in the community assessment.

Community Benefit Priority Setting  Process  Refrain from jumping to solutions

Priority setting methods  Relative Worth  Forced Ranking  Delphi Method  Hanlon Method  Delbeq Method  Source: Barnett, K. (1996). Setting Priorities to Address 21st Century Realities: A Review of Existing Approaches. Western Consortium for Public Health

Relative Worth Each participant receives a fixed number of points (for example, 100 points). These points can be distributed among the items to be prioritized in whatever way the participant desires. Participants can distribute points in a number of ways:  Give all points to a single, very important item.  Distribute points evenly among all items (if none is more important than another).  Distribute some points to some items, no points to other items.  In the tabulation, items are given priority ranking according to the total points the group assigns.

Forced Ranking  Health needs are ranked separately on a scale.  For example, if there are ten items, the most important item is assigned a "1," the second most important item is assigned a "2," and so on down to the least important item, which receives a "10.“  In the tabulation, the item that receives the lowest number of points is assigned highest priority, the item that receives the second lowest number of points receives second priority, and so on.

Delphi Method (1) 1.The coordinating group assembles participants with knowledge and experience in the issue to be addressed. 2.Needs are identified and presented to participants for feedback. A deadline for returning responses is given. 3.The coordinating group records all responses and distributes them to participants.

Delphi Method (2) 4. Participants are asked to review the responses and add additional ideas or delete ones considered not important or not feasible. Participants then choose the three or five most important ideas and rank these in descending order of importance. 5.Results of the rankings are collated and analyzed.

Delphi Method (3) 6.Findings are returned to participants who are again asked to rank the top three or five preliminary priorities. Additional rounds may be implemented if necessary. 7.Results are collated and categorized. An overall ranking is determined. Delphi enables participants to examine group responses with each succeeding round, and to alter their views or to provide a rationale for sustaining a divergent opinion.

Hanlon Method (1) There are three central features of the method: 1.Focuses on identifying explicit criteria to be considered in setting priorities. 2.Ability to organize factors into groups that are weighted relative to each other. 3.Allows for modification and individual scoring of factors.

Hanlon Method (2) Criteria for scoring of factors and subsequent priority setting include:  Size of the problem  Seriousness of the problem  Estimated effectiveness of intervention(s) under consideration  PEARL (i.e., propriety, economic feasibility, acceptability, resource availability, and legality)

More on PEARL  P = propriety: is an intervention suitable?  E = economics: does it make economic sense to address the problem?  A = acceptability: will this community accept an emphasis on this problem and will they accept the proposed intervention?  R = resources: are resources available?  L = legality: do the current laws allow the intervention to be implemented?

Delbeq (1)  The Delbeq "Two Step" method involves the use of a nominal group process to develop a detailed set of priority issues, and the subsequent sharing of issues and development of a consolidated list of priorities.  The term "nominal group" is used to underline the highly controlled dimension of the process.

Delbeq (2)  In the first stage, participants are asked to privately record their major concerns on a sheet of paper.  Facilitators then go around the group to elicit their priority concerns. This is usually done anonymously, by asking for a limited list (2 or 3) of priority concerns to be handed in to facilitators. These are recorded on a white board.

Delbeq (3)  An alternative is to hold a "round robin" where priority concerns are elicited from participants one at a time. No comment is permitted during this stage.  In the second stage, facilitators take participants through a controlled discussion; first to clarify priority concerns, and then to consolidate common issues.

Delbeq (4)  Finally, for health planning efforts where large lists of priority concerns are typically generated, participants may go through a ranking process to limit the number of potential options.

Tools  ACHI Community Health Assessment Toolkit  ASACB User’s Guide  Healthy People 2010 Toolkit – Priority Setting Worksheet

Examples  Presbyterian Intercommunity Hospital, Whittier, CA  Scripps Health, San Diego, CA

PIH  Summary of indicators  Priority health template  Value and probability grid (alternative = importance and feasibility)

Scripps Health  Community Benefit Plan, pages unitybr09.pdf

From Assessment to Plan  Needs Assessment  Priorities  Programs  Community Benefit Plan

Community Benefit Plan (1) The Community Benefit plan is a tool for you to connect the needs assessments, priority setting, program selection and accomplishments. Use it to:  Respond to internal and external pressures  Show your efficient use of limited charitable resources

Community Benefit Plan (2)  Support your plan to improve community health  Promote accountability and communication (transparency)  Build public trust, support community relations The Plan outlines what you are going to do to meet the identified, unmet needs in your community.

Community Benefit Plan (3)  Do include an overview of the needs assessment.  Do outline the priority setting process, including criteria and decision makers.

Community Benefit Plan (4)  Do identify the priority programs.  Do acknowledge that not all priorities can be addressed.

Questions? Melissa Biel