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Social Science & Medicine 63 (2006) 11211134 www.elsevier.com/locate/socscimed

Using participatory action research to build a priority setting process in a Canadian Regional Health Authority
San Pattena,, Craig Mittonb,c, Cam Donaldsond
b

Centre for Health and Policy Studies, University of Calgary, 3330 Hospital Drive N.W., Calgary, Alta., Canada T2N 4N1 Centre for Healthcare Innovation and Improvement, British Columbia Research Institute for Childrens and Womens Health, 4480 Oak Street, E414A, Vancouver, BC, Canada V6 H 3V4 c Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada d Centre for Health Services Research, School of Population & Health Sciences and Business School (Economics), University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne NE2 4AA UK Available online 15 March 2006

Abstract Due to resource scarcity, every health system worldwide must decide what services to fund, and conversely, what services not to fund. In order to institute and rene a macro-level priority setting framework within a large, urban health authority in Alberta, Canada, researchers and decision makers together embarked on a participatory action research (PAR) project. The focus of this paper is the PAR process in this context, including reections from PAR participants about the contribution of the research methodology to their own practice as health care managers and clinicians. The use of qualitative research in health economicsin this case, to rene the application of a macro-level priority setting modelis a relatively new advancement. PAR proved to be an appropriate and helpful approach to introducing a theoretically driven model of macro-level priority setting within a large, complex health organization. However, it is important that support for the change is sustained as long as necessary to embed the new practices into the organization. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Priority setting; Participatory action research; Health economics; Canada

Purpose This article describes the unique application of participatory action research (PAR) methods as a means of building a macro-level priority setting
Corresponding author. Tel.: +1 403 245 3465; fax: +1 403 283 5897. E-mail addresses: san.patten@shaw.ca (S. Patten), cmitton@exchange.ubc.ca (C. Mitton), Cam.Donaldson@newcastle.ac.uk (C. Donaldson).

framework within a large, complex health organization. The methods for the project as a whole are described in detail and PAR is critiqued as a change mechanism in this context. The PAR project manifested as seven phases, the rst four of which have been reported elsewhere (Mitton, Patten, Waldner, & Donaldson, 2003); this paper reports on phases ve through seven, providing further insights on PAR as a means of introducing the program budgeting and marginal analysis (PBMA) framework and facilitating its transfer and uptake.

0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.01.033

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Finally, in response to suggestions that PBMA succeeds only when health economists are actively pushing its agenda (Mitton & Donaldson, 2004), data from decision makers is presented regarding the role of the researchers in introducing priority setting practices in the Calgary Health Region (CHR). The overall purpose of this paper is to highlight key ndings related to the application of PAR as a means of introducing a theoretical priority setting model, and in particular to report on the sustainability of change enacted through PAR once there was no direct researcher involvement. In so doing, this paper builds on previous work in which the institutional context is described as a key driver for the ultimate success or failure of the application of technical and/or so-called rational approaches to health care priority setting (Jan, 2000; Mitton & Donaldson, 2004). Background The CHR is one of nine integrated regional health authorities in the province of Alberta, Canada, which provides services across the continuum of care. In the CHR, all clinical and preventive services are overseen by one of seven Executive Director/ Medical Director pairs who comprise the senior management team, and in turn report directly to the Chief Operating Ofcer and the Chief Medical Ofcer who are two of seven vice-presidents comprising the Executive level of the organization. In addition, Regional Clinical Department Heads oversee clinical specialty areas and work alongside the Executive Director/Medical Directors in setting clinical priorities. The total annual operating budget of the CHR is approximately CAD$1.5B (CAD$1EUSD$0.82), with the majority of physician reimbursement falling outside this budget. In Fall 2001, a need was identied within the CHR for an explicit, systematic process for setting priorities and allocating resources across broad service areas. In response to this, researchers at the University of Calgary teamed with decision makers in the CHR in order to develop and implement a macro-level approach to priority setting based on a recognized health economic framework that had previously been used at more micro levels of care in health organizations (Donaldson & Farrar, 1993; Halma, Mitton, Donaldson, & West, 2004; Madden, Hussey, Mooney, & Church, 1995; Peacock, 1998). The approach used

in the CHR, based on the PBMA framework, is described in detail elsewhere (Mitton et al., 2003). A seven-phase PAR project was initiated in the CHR late in 2001 to develop and implement a macro-level priority setting model. PAR is an approach to develop knowledge from experience and engage stakeholders in becoming more aware of conditions, while learning to take actions to alter the practices of the organization (Fals-Borda & Rahman, 1991). This project included the study of existing priority setting practices and structures, provision of education to senior decision makers and clinicians about economic principles relevant to priority setting activity, and involved action towards the development and implementation of a macro level approach to priority setting. The main outcome of the project was the development of a new process for priority setting, as conceptualized by the organization, as well as a series of recommendations to the CHR for process renement and long-term sustainability of explicit, evidence-based priority setting practices. The priority setting process as developed not only addressed the challenges identied by CHR decision makers with respect to PBMA, but also was an important contribution to the health economics and policy literature, noting that previously an explicit resource re-allocation process across major services areas had not been reported within a health authority with jurisdiction across such service areas (Mitton et al., 2003). A further signicant outcome of this project was that senior managers and clinicians in the CHR gained a better understanding of priority setting at a macro level across major program areas, and have developed a set of skills and strategies that directly contribute to improving the organizations priority setting practices. This latter outcome is particularly important as previous work has shown that decision makers in health authorities often lack the necessary skills to set priorities and allocate resources (Lomas, 1997; Mitton & Donaldson, 2002). Application of PAR methods When a PAR approach is taken, it is important to examine not only the outcomes of the project but as well the process used in achieving those outcomes. In this section, we describe how PAR was applied within the context of efforts to build a more rigorous macro-level priority setting process in the CHR.

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PAR project PAR is a form of social research that blends knowledge generation with organizational action and change (Greenwood & Levin, 1998). PAR is different from conventional health research in that it focuses on knowledge for action rather than knowledge for understanding (Cornwall & Jewkes, 1995). In our case, the intent was to foster change in the direction of a more systematic, evidence-based priority setting process at a macro-level within the CHR. Before engaging in a change process, it was important for the researchers to understand the organization and its current priority setting practices. PAR became the method of choice once the research objectives were established, and once the researchers appreciated the complexity of PBMA from the perspective of those applying it. PAR inherently takes account of local priorities, processes and perspectives (Cornwall & Jewkes, 1995). Together, the researchers and senior decision makers within the CHR established the research agenda, generated the knowledge necessary to transform the organizations practices, and incorporated the resulting approach into practice. Through the use of qualitative methods, decision makers in the CHR were able to understand macrolevel priority setting within their own context, and thus, together, decision makers and researchers were able to develop the PBMA model inductively through immersion in the practice setting (Lincoln, 1992). The PAR project was carried out by a team of two health economists, a qualitative researcher and senior managers and clinicians. Throughout the project, there were close interactions between the investigators and the investigated, with explicit efforts by the researchers to understand the context within which the macro-level priority setting approach was being developed. The project followed general principles of qualitative research (Miles & Huberman, 1994) in that: (1) the researchers maintained intense and prolonged contact with senior decision makers within their own work setting; (2) the researchers sought to gain a holistic overview of the context under study (i.e., the organizations structure and culture, its history and procedures with respect to priority setting, its explicit and implicit rules, and its guiding principles); and (3) the researchers attempted to capture data from the perspective of those individuals who would have to implement PBMA on an ongoing

basis. The PAR project was a naturalistic exploration of how the CHR applied PBMA, revolving around the CHRs priority setting processes. Project phases In initial discussions between the CHR and the research team in Summer 2001, it came to light that the organization was not only facing tough budgetary decisions (i.e., a decit of approximately CAD$40 M) for the 2002/2003 scal year, but also that senior decision makers wanted to develop and implement a longer term, sustainable approach to macro-level priority setting. The PAR approach allowed the researchers to get inside the organization and discover from within the barriers and facilitators encountered in developing a macro-level priority setting model. The researchers took the lead in writing the proposal but signicant input was also provided by the decision makers. The researchers circulated the research proposal to the decision makers, reached agreement on the aim to develop a macro-level priority setting model, and built relationships with key participants who would likely inuence the processes from within. Ethics approval was received from the University of Calgary Conjoint Health Research Ethics Board in October 2001. The methodology of the PBMA study was reexive, exible and iterative (Cornwall & Jewkes, 1995). While there were preliminary plans for the project, phases changed from their original conception or emerged as new phases during the implementation of the PAR project. In the end, the PAR project emerged as seven phases comprising development of the PBMA model, data collection, and application of the PBMA model (both with and without researchers involvement) (see Tables 1 and 2). Data collection The research components of the PAR project combined qualitative data collection methods of document review, participant observation, in-depth interviews and focus groups. Throughout the PAR process, the health economists participated in the priority setting exercise not only as researchers, but also as consultants. Participant observation notes were taken during all priority setting meetings and training presentations, as well as during the focus groups and interviews. The researchers joined

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Table 1 Participatory action research phases and timetable

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S. Patten et al. / Social Science & Medicine 63 (2006) 11211134 Table 2 Phases of the PAR project 1. Examination of recent and current priority setting practices Researchers attended priority setting meetings of senior managers and clinicians between October 2001 and September 2002 to document decision-making processes, sources of evidence, group dynamics and roles, and organizational culture. This allowed the researchers to develop a holistic understanding of priority setting practices in the CHR, and make note of both explicit and tacit aspects of the CHRs organizational culture. As well, a social analysis of the decision-making structure of the organization was conducted in order to ensure that all relevant members were included in the PAR process 2. Reection upon recent and current priority setting practices Reections were gathered from the senior managers and clinicians involved in macro-level priority setting about their current practices and processes, through participation in a focus group, to provide information about their involvement, inuences, needs for greater understanding, concerns, and suggestions for improvement with respect to the CHRs recent and current macro-level priority setting practices, and one-on-one qualitative interviews, to gather more in-depth and personal reections on group dynamics, political and interpersonal inuences, and the role of personal values in priority setting practices 3. Introduction of priority setting economic principles CM and CD provided explicit training to members of the senior management team to generate the knowledge necessary to transform the organizations priority setting practices. While the researchers provided ongoing training throughout the priority setting meetings attended between October 2001 and September 2002, a number of specic presentations to senior management team and other decision makers within the organization were also held during this period. Training included introduction to fundamental economic principles of opportunity cost and marginal analysis, and introduced the PBMA framework for priority setting activity. During key presentations, participant observation notes were taken (by SP) to document group dynamics, improvements in understanding, acquisition of new concepts and skills, mobilization for action (e.g., levels of motivation), and potential challenges in implementation 4. Development and implementation of the priority setting model Researchers and stakeholders collectively developed and rened a macro level priority setting approach within the organization in an iterative manner. That is, the researchers proposed information and processes from the literature and their previous experience with priority setting in other contexts, and the decision makers rejected or accepted this information and added to it from their own experience. The initial priority setting process was developed and implemented (to inform budgetary decisions for the 2002/2003 scal year) over a three-month period (JanuaryApril 2002) through bi-monthly meetings 5. Framework renement Reections and suggestions for renement were obtained from the decision makers who had just completed implementation of a novel approach to priority setting at a macro-level across major service portfolios in the CHR. A second focus group (same participants as phase two) and a further round of one-on-one interviews (new individuals) provided information pertaining to specic challenges encountered during framework implementation and suggestions for process improvement. The data also included reections on the PAR project itself, its processes and outcomes, as well as prospects for sustaining the framework 6. Independent application of priority setting model Researchers departed from the process. CHR senior managers implemented the priority setting model independent of the health economics researchers for development of the 03/04 scal year budget 7. PAR follow-up Interviews with senior managers to gather reections on their rst independent application of the priority setting model (without researcher involvement) 1125

the priority setting meetings to conduct participant observation and develop a contextual understanding of the group dynamics, roles and salient issues to be explored in interviews and focus groups, as well as in the longer-term follow-up. Current priority setting practices were also examined through a review of relevant written documents such as decision-making tools, internal criteria on which priority setting decisions would be based, and survey results from previous research with CHR decision makers (Mitton & Donaldson, 2002).

In this paper, we report information gathered from the interviews and focus groups conducted in phases ve and seven of the PAR project. In phase ve, members of an internally struck priority setting committee (n 8) participated in a focus group to assess the processes and outcomes of the implementation of the PBMA approach and to provide suggestions for improvement. In addition, one-onone qualitative interviews were conducted with eight other senior managers to gather more in-depth and personal reections on specic challenges encountered during the implementation of the PBMA

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1126 S. Patten et al. / Social Science & Medicine 63 (2006) 11211134 Table 3 PAR phase ve focus group and interview guide Focus group questions 1. Overall, was the priority setting process fair and transparent? 2. How well is the publicity condition met in this region? 3. How well is the relevance condition met in this region? 4. How well is the appeals condition met in this region? 5. How well is the enforcement condition met in this region? 6. Were the criteria used in the decision making process clear and appropriate? What would you change? 7. What have you learned over the last four months about communication and roll-out (feasibility) with respect to the priority setting process? 8. How best should cross-portfolio priorities (disparate patient groups) be compared? 9. What would you do differently for future priority setting exercises in the RHA? Interview questions 1. Was the priority setting process fair and transparent? How do we ensure it is fair in the future? 2. How did the input of the researchers (health economists) inuence your understanding of MMA? 3. Who should be making priority setting decisions; is it the right mix? How inclusive should the process be? At what stage(s) should the Directors and Clinical Department Heads be involved in the priority setting process? 4. How should we educate the public and build their engagement in decision-making? 5. How best should cross-portfolio priorities (disparate patient groups) be compared? 6. In what ways should or could PBMA be used more broadly in the organization (i.e., beyond the operations portfolio)? 7. What would you do differently for future priority setting exercises in the RHA?

Table 4 PAR phase seven interview guide 1. 2. 3. 4. Please describe the macro-level priority setting process conducted this past year in the Calgary Health Region In your opinion, and thinking specically in comparison to the previous year, what were the key strengths of the process this year? What were the key weaknesses of the process this year? Do you think the process should be continued in future years? If so, how specically do you think the process could be improved or adapted in future years? 5. Do you think that the public could play a more explicit role in the process as it stands currently? What role might this be? 6. Do you think that evidence could play a more central role in the process? How exactly do you see this? 7. Based on the amount of resources freed up for re-investment, it would seem that there was little or no detriment in not having researchers or health economists directly involved in the process. Would you agree with this? Why or why not?

framework, as well as strategies to address those challenges. The focus group and interview guides used in phase ve are included in Table 3. Phase seven was a nal data collection period in the spring of 2003 to gather follow-up reections from CHR managers after they had independently applied PBMA (in phase six) without input from the researchers, to guide the 2003/2004 budget. It is important to note that all three researchers were entirely absent from the application of PBMA in the 2003/2004-budget cycle. There were no external funds remaining to support further priority setting research with the Region and two of the researchers left Canada, thus leading to an opportunity for a natural experiment of sustainability and development of the PBMA process in their absence. During phase seven, approximately 1 year after the re-

searchers removed themselves from the CHRs priority setting processes, one-on-one qualitative interviews were conducted with 17 senior managers and clinicians to gather the reections on specic challenges encountered during the independent implementation of the process, as well as to identify strategies to address those challenges. This interview guide is found in Table 4. Sampling strategy Purposive sampling was used to select key informants based on the perspective and role of the individuals within the organization, as well as information that had already been gathered in previous phases and remaining gaps in understanding (Stringer, 1999). The sampling comprised of

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two simultaneous purposive sampling techniques (Patton, 1990): (1) intensity sampling for selection of experiential experts; and (2) maximum variety sampling for selection of heterogeneous participants representing a wide range of clinical and community health services, experience and involvement in macro-level priority setting, and level of understanding of economic principles. In practice, this meant that the researchers and a senior CHR representative discussed the roles of various managers and clinicians on the senior management team and identied the relevant samples for the interviews in phases ve and seven. Data analysis With informed consent from participants, the interviews and focus groups were audio taped and then transcribed verbatim. Participant observation notes and interview and focus group transcripts were entered into QSR N5 software for storage, coding, text search and retrieval, and theme mapping. Through thematic analysis, the researchers identied and dened salient themes and recurring ideas or concepts. The data were coded inductively with a thematic coding scheme that evolved using a constant comparative method of analysis (Glaser & Strauss, 1967). Each iteration of comparing and contrasting themes and concepts as they emerged involved both data reduction as the volumes of written data were organized into manageable chunks, and interpretation, as the researcher brought meaning and insight to the textual data (Marshall & Rossman, 1989). As categories of meaning emerged, the researcher searched for those that had internal convergence and external divergence (Guba, 1978). Participants reections on the PAR project Participant reections allowed the researchers to assess the extent to which the PAR approach was an effective means of introducing, customizing and building capacity to implement the new macro-level PBMA approach. The key features of the PAR approach in facilitating the introduction and implementation of PBMA are summarized below. Need for change identied by management A prerequisite for PAR is that the action or change is deemed as important to the people most

affected. The PAR project was initiated in order to introduce one possible priority setting approach, PBMA, in a time of major scal challenge and offer assistance in adapting and applying it to the context of the CHR. Fluidity of researchers roles The health researchers were seen to serve the roles of educator, process facilitator, health economist, content expert, management consultant and health researcher. This uidity of roles was advantageous in that the senior managers perceived the researchers as members of the group and did not act for the benet of the researchers, or for the benet of the research project. Recognizing change as an incremental process The PAR project was initiated with the expectation that change, both in terms of individual professional development and organizational development, would occur in the direction of a more rigorous macro-level priority setting model. Even though the CHR, upon completion of the PAR project, had tools to assist in priority setting, the organizations macro-level priority setting model is only in the early stages of becoming integrated as a part of its regular practice. Capacity building In the interviews following the 2003/2004 budget planning process, decision makers attributed the sustained and independent application of the PBMA process to the participatory approach taken in the initial development in which CHR leaders built a thorough understanding of its principles and processes. Overall, capacity was built through intense collaboration in the rst year of PBMA, then, once the basic concepts were embedded, decision makers were able to continue with subsequent application on their own. Merging theory and practice A key component of PAR is that the research process brings theory and practice into closer alignment. In this case, the PAR project brought an objective theoretical perspective to the difcult task of macro-level priority setting. One senior manager described the principal contribution of the

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PAR project as the introduction of economic principles combined with health economists practical suggestions. Recognizing the theory practice divide One Executive Director felt that the CHR needs to use the PBMA process pragmatically and apply it in appropriate contexts. In the follow-up interviews, one senior manager stated that the health economists provided the CHR with a solid theoretical frame of reference. Despite this learning by senior managers, there was a bit of frustration that the theory is difcult to apply in reality. Internal commitment In the interviews following the 2003/2004 application, some of the senior managers expressed an overall commitment to implementing the new process and felt the rationale for the new approach to priority setting was rmly implanted. In phase ve, one of the Vice-presidents attributed the successful integration of the PBMA model to strong proponents who would remind their colleagues in senior management of the rules and the processes. Internal commitment was seen as key to moving forward with PBMA over time. External objectivity The decision makers felt that external guidance of the priority setting process was very valuable in building a fair and rigorous process. One Executive Director felt that external researchers are more able to ll an objective monitoring and mentorship role to the PBMA process than staff members would be: As a researcher you dont have any turf to protect other than the process, the integrity of the process and we need somebody to protect the integrity of the process. Strengthening partnerships Some of the CHR participants felt that the PAR project encouraged merging of different areas of health expertise, building mutual understanding both within the CHR and between the CHR and its academic partners. Another positive outcome of the collaboration built through the PAR project is that it helped to overcome previous negative perceptions of health economists.

Discussion We examined the application of PAR methods that were used to introduce, adapt and implement a new priority setting approach in the CHR. The application of PAR contributed two major ndings: (1) there are several key features of PAR that facilitate the merging of theory and practice in setting health services priorities; and (2) a complex and new priority setting model with unfamiliar concepts for many decision makers can be successfully and independently implemented when PAR is used to introduce the model in a manner that accounts for the unique context of the host organization. Overall, the use of a PAR approach, with its inherent requirement of researcher immersion and context-specic understanding, can be viewed as an effective means for promoting organizational change. PAR was a suitable method for introducing PBMA to the CHR, as it helped the researchers and decision makers to discover more about the applicability of economics-based techniques in complex organizational settings. This study adds to a developing literature in which qualitative methods have been applied to health economics research (Coast, 1999; Coast, McDonald, & Baker, 2004), in research on priority setting to examine citizen involvement in rationing decisions (Coast, 2001), to describe decision making processes and the role of health economics in health authorities (McDonald, 2002), and in research on allocating health care resources on the basis of the size of the health improvement (Dolan & Cookson, 2000). The current focus of using PAR as a vehicle for applying an economics-based approach to priority setting is, to our knowledge, novel. This project has demonstrated the value of PAR as an approach to bridge the gap between health economics theory and the practice of macro-level priority setting in a health region. A number of the elements of this project that contributed to its success in initiating an organizational change process within the context of macro-level priority setting are highlighted in Table 5. While some decision makers were condent that the organization has the capacity to independently implement the PBMA model without further assistance from external parties, most participants felt that even with the positive change towards a fair and rigorous priority setting process, the change is best sustained with continued support from external health economists. The CHR participants gained a better

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S. Patten et al. / Social Science & Medicine 63 (2006) 11211134 Table 5 Elements contributing to organizational change Element d Real pressures were faced by CHR decision makers in dealing with a large budget decit d Dual management consultant/researcher role served by the health economists d Researchers were permitted to immerse themselves in the context within which the priority setting model would be implemented in order to fully understand the complexities and pressures faced by the CHR participants Researchers were willing to allow the PAR project to proceed naturally through the various phases of action, research and change interventions Result d Provided strong internal impetus for developing a more rigorous and fair priority setting model d Lended credibility to the research project and provided professional development opportunities for the CHR participants d Allowed a customized and contextually appropriate priority setting model to be developed and implemented 1129

Avoided the feeling of imposition upon the senior managers who were facing their own realities

understanding of health economics principles and a closer alignment between theoretical and practical priority setting models. Overall, the decision makers felt that the researchers played a central role not only in introducing the health economics theory, but also in stimulating professional self-reection and creating advancement towards improved organizational practice. About achieving change The PAR methodology served as an important mechanism for initiating and sustaining change of practice. Change occurred in the CHR at both the level of individual professional practice and organizational structures and processes with respect to priority setting and consciousness of health economics principles. The researchers served as catalysts to help senior decision makers dene the needs for macro-level priority setting and examine and improve current practices. There were several elements of action throughout the research process: (1) the meetings and focus groups strengthened relationships and understanding between individuals and groups from a variety of positions in the organization; (2) the exploratory phases (one and two) put issues on the agenda for discussion and raised awareness about specic challenges, such as identifying different viewpoints between managers and clinicians; and (3) the development and implementation of a novel approach to priority setting in the CHR. PAR served in this case both to alleviate a problem (i.e., the need to develop a rigorous process

for macro-level priority setting in the CHR), and to generate new knowledge about the application of a specic approach to priority setting under these conditions. Thus, the PAR project simultaneously achieved both problem solving and theory building. The PAR project facilitated a critically reective process in which theory about the application of a framework for macro-level priority setting emerged from the practice of applying the model in the reallife setting of the CHR. This research project aligns with the four main characteristics of action research dened by Hart and Bond (1995): (1) collaboration between researchers and practitioners; (2) solution of practical problems; (3) change in practice; and (4) development of theory. This project demonstrated that qualitative methods applied to health economics creates models and practices that are grounded in the real world of health care provision. The main intervention that created the impetus for change occurred through phase three, i.e., building decision makers understanding of health economic principles. This change intervention largely occurred as experiential learning and consciousness-raising about relevant economics principles. The change intervention was discreet and perhaps not always recognized by the participants, and included subtle outcomes such as building relationships, opening up lines of communication, reframing issues, and changing the ways in which problems are discussed. Change was facilitated by the willingness of both researchers and managers to approach the PBMA model in a spirit of inquiry. The structure and values of the organization also facilitated the success of the

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PAR project. Because group decision-making is essential for authentic commitment to organizational change, senior management team members worked together as an expert panel of senior managers and clinicians to exert self-direction in the application of the new framework to their priority setting practices. Introducing the framework through the PAR process avoided a topdown approach of imposing a model from the Executive level of the organization, and fostered both empowerment and engagement. One of the major lessons learned through this PAR project was that even if members of a group welcome, value and are committed to change, it should not be assumed that the change is sustainable. While many of the senior management team members felt that organizational change had been initiated in the CHR through the introduction, customization and one budget cycles application of the PBMA framework, some felt that this organizational change was not yet self-sustaining without continued support from external health economists. This perceived need for sustained consultation and assistance indicates that organizational change is a process that may take more time than typically allocated from a research projects perspective. Moreover, in the case of this PAR project, the organizational change involved a theoretical eld of learning (i.e., health economics) that was outside the knowledge domain of some of the group members. It should be noted, however, that even though the group members felt that continued support from an outside expert would be necessary to sustain the change, they did successfully implement PBMA through a second budget cycle without any assistance from health economists, and have just recently completed their third planning process with the PBMA approach. It is thus reasonable to assume that the PBMA process is becoming entrenched in the institutional ethos of the CHR. Despite numerous personnel changes over the last year in even the most senior positions, PBMA continues to be referred to as the priority setting and budget planning process of choice. While it is not possible to place a causal relationship on the use of PAR necessarily resulting in successful longer-term application of PBMA, in our case it is clear that PAR was a vehicle that enabled organizational change away from historical and political resource allocation towards the use of an explicit, evidence-based approach to priority setting. Sustained use of PBMA has been shown in

a recent international survey to occur in roughly half of the organizations in which it has been applied, but almost all of these applications have been within specic programs of care (as opposed to across major service areas) and the time period of sustained use was not specied (Mitton & Donaldson, 2001). As such, additional follow-up in the CHR is planned for 2006 by a UK-based researcher who was not involved in the initial research to examine the longer-term role and effects of PBMA in the organization. PAR enables decision makers to be engaged in their own realm, recognizing the messiness and complexity of health care decision-making while providing a real vehicle for change. Knowledge transfer is often viewed as an external process of getting evidence into the hands of decision makers, but a PAR perspective takes a more in depth and engaging view where researchers and decision makers over time can develop relationships and struggle to come up with real-world solutions that may seem far from the technical solutions so often derived within the health economics paradigm. Indeed, it has been argued that health care decision maker attitudes are at odds with rational models for decision-making (McDonald, 2002). PAR allows the decision-making context to be grappled with, and it is setting PBMA in context that in our view is ` -vis the major contribution of this work vis-a previous studies. Roles and relationships To ensure a successful PAR project, it is important that the processes of dening the problem and formulating the research topic/question are collaborative. The researchers wished to advance the body of knowledge on macro-level priority setting, while the decision maker partners required an explicit process to set priorities and allocate resources in their organization. It was serendipitous that the research questions of interest to the researchers happened to match the real-world scal constraints faced by the decision makers. However, previous research in Alberta and elsewhere has shown a lack of knowledge about explicit approaches to priority setting in health authorities, but, nevertheless, a desire to develop one (Mitton & Donaldson, 2002), so it was not a surprise to the researchers to nd such willing partners. Participation by the CHR decision makers was variable, with deeper and more central participation

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at some stages than others. Participation by CHR decision makers manifested itself in two forms: (1) consultative participation in which CHR managers had discussions with researchers before, during and after the PBMA model was introduced and implemented; and (2) collegial participation during which researchers and CHR managers collaborated as colleagues with different skills or expertise to offer in a process of mutual learning. The PAR project aligned with many of the principles of participatory research (IHPR, 2000) with respect to the nature of participants involvement, origin of the research question, purpose of the research, process and contextual implications, opportunities to address the issue of interest, and nature of the research outcomes. In general, the researchers role in PAR is to act as a catalyst in helping members of the organization to dene or think differently about the problem, and to implement and monitor change that occurs (Springer, 1999). Specically, the researchers served as professional experts, working with key members of the organization to design the project, gather data, interpret ndings, and recommend action to the sponsor organization. The researchers facilitated the engagement and understanding of the users of the developed framework, and helped to pave the way for the implementation of the improved model. The researchers played an active role in the senior management team meetings by providing input about economic principles or giving input into the development of priority setting processes. CHR decision makers jointly inquired into a new process for macro-level priority setting, gained professional development, and engaged in self-reection (both at an individual and group level) about their priority setting practices. At the same time, the CHR decision makers built a commitment to investigate and improve their work, and clarify their own roles in establishing an improved priority setting exercise. Overall, the senior management team members worked alongside the action researchers to analyze and solve their own issues, devise action plans to improve practice, and evaluate such plans. Transferability The current study was carried out in a single Canadian jurisdiction. This arose out of the necessity to get inside a health organization in an attempt to build the bridge between rational decision-making models and the real world. Never-

theless, there are a number of reasons to suggest that the results reported herein (i.e., not the specic allocation decisions made but rather the application of PBMA using a PAR approach) are in fact transferable. First, all health care organizations around the globe, including the CHR, are faced with limited resources and thus the need to make choices about what to fund and what not to fund. Surveys across countries have shown that resource allocation typically follows historical patterns, with limited re-allocation across program areas despite decision maker desires to become more proactive in setting priorities (Miller, 1997; Mitton & Donaldson, 2002; Mitton & Prout, 2004). Second, many of the barriers to adopting a change process more generally (e.g., perceived information decits, uncertainty in decision-making) (McDonald, 2002) were most certainly apparent in the CHR. Thus, while any given organization may claim that PBMA through PAR is not possible, there is no overtly obvious difference between the CHR and other health authorities elsewhere responsible for meeting the needs of the population. Third, the lessons about PAR from this studyin terms of relationships, recognition of barriers, collaborative development and implementationfall within the broader PAR literature. The novelty has been in applying these concepts, and identifying relevant lessons within a health care organization challenged with moving towards an explicit approach to setting priorities. What remains is to pursue action research on priority setting in other countries to test many of the lessons from this study. Such activity is currently being undertaken in the UK by researchers at the University of Newcastle upon Tyne and has also been proposed in other areas of the UK. Challenges and study limitations The unpredictable nature of action research necessitates a exible rather than a rigid research design. The PAR process was not linear and did not follow discrete stages as the researchers initially envisioned. Action, research and change interventions interacted throughout the PAR project as dynamic and overlapping processes. In each phase, one aspect (action, research or change intervention) dominated, although other components were still happening. This uidity in the process of PAR makes it difcult to actually measure the impact that the health economists exerted upon the change process. While the researchers envisioned a certain

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orderly progression through the various phases of the PAR project, moving from an examination of current practices, to delivery of training and consultation, to implementation of a new model, and nally to reection, there were times during the project that the CHR participants exerted their own sequence of events, as appropriate for the reality of their work. Rather than providing discrete and sequential series of training sessions in health economics principles, for example, the researchers were asked to provide pieces of training (the change intervention) throughout the PAR project as needs for more information arose. Another signicant challenge was the pressure of limited timelines. PAR requires adequate time to allow change to happen without participants feeling that it is imposed. The PAR process was constrained by externally imposed deadlines from the provincial health ministry, in that a budget for the CHR had to be formulated. Acknowledging that it is not always possible or advisable to try to hurry up the process of PAR, the researchers nonetheless were also working under the constraints of research funding timelines. Ideally, a PAR project progresses to the point that ownership for the change in practice is shifted to the extent that researchers are removed from the process, and the change or action is fully self-sustaining. Finally, the follow-up interviews with CHR senior managers and clinicians were conducted by members of the research team who the informants identied as those proposing the method. It is acknowledged that this may, potentially, have led the informants to be unwilling to be completely honest in their reectionsparticularly if the informants had negative feelings about the research approach. On one hand, the informants feedback on the overall research approach may have be perceived as more reliable if the follow-up interviews had been conducted by an interviewer completely external to the PAR project. On the other hand, the richness of the information from the follow-up interviews and focus groups was made possible by the in-depth understanding and observations of the qualitative researcher who had been involved through the entire project. Further study It was stated in a survey of authors of PBMA studies that this approach will only work if theres direct involvement of health economists or aca-

demic health researchers (Mitton & Donaldson, 2001). However, in priority setting experiences with other health authorities within specic program areas, we have learned that managers do not always feel the need to be supported by researchers (Halma et al., 2004). In essence, it seems that decision makers need to have reinforcement of the theoretical principles behind PBMA, whether it is from an external health economist or an internal support personnel within the given organization. The role of such an internal consultant would be to ensure that the PBMA process is sustainable and to build broad cross-organizational commitment. Rather than relying on external experts, it would be more sustainable for PBMA processes to be mentored from within. Thus, health organizations interested in developing an explicit approach to priority setting at the macro level may best be advised to strike a dedicated priority setting team to coordinate PBMA activities and provide both practical and technical support to decision makers. In addition, this qualitative inquiry has led to further research proposals, to evaluate the piloted macro-level priority setting framework in other health organizations in both Canada and the UK. Themes generated through the interviews and focus groups, such as factors for success of using an explicit approach to priority setting, the implementation of incentive systems to foster stakeholder engagement, the use of evidence to support decisions to improve patient outcomes, and the affect of a framework on changes in actual health outcomes, will be explicitly tested in these further contexts. Conclusions In summary, PAR proved to be an appropriate and helpful approach to introducing a theoretically driven model of macro-level priority setting within a large, complex health organization. The CHR managers and academic researchers engaged in cooperative inquiry from different perspectives but with the common goal of implementing PBMA within the CHR. The PAR process achieved two major outcomes: (1) the merging of theory and practice with respect to a specic framework as a macro-level priority setting model within the CHR; and (2) the development of skills and understanding amongst CHR senior managers and clinicians enabling them to apply a novel priority setting framework within their own work reality. Next steps would include consideration of striking a

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priority setting team to guide future processes, and outside the CHR, further investigation of macrolevel practices in other contexts. This application of PAR highlighted its value in facilitating the transfer of theory to practice, which, if conducted in a truly participatory manner, can create signicant change in practice within a relatively short period of time. We would recommend the application of PAR in similar contexts where a theoretical model must be introduced to a group of decision makers with the aim of aiding and improving their professional practice. However, it is important that support for the change is sustained as long as necessary to engrain the new practices into the organization. We would encourage other health organizations to apply PAR in building not only fair and rigorous processes for making difcult funding decisions, but in other areas of management practice as well. Not only can insights of decision makers improve the quality of research and ensure face validity, their involvement has important implications for the sustainability and appropriateness of theoretical models being transferred to practice. Acknowledgments The authors thank the members of the senior management team in the Calgary Health Region for their participation in this project, as well as the Canadian Health Services Research Foundation for funding this work. Craig Mitton receives salary support from the Canadian Priority Setting Research Network, and during 2003/2004, was an ESRC Advanced Institute of Management Research (AIM) International Fellow. Cam Donaldson holds the Health Foundation Chair in Health Economics, and during 2003/2004, was an AIM Public Services Fellow. The views expressed are those of the authors, not the Calgary Health Region or the funders.

References
Coast, J. (1999). The appropriate uses of qualitative methods in health economics. Health Economics, 8, 345353. Coast, J. (2001). Citizens, their agents and health care rationing: An exploratory study using qualitative methods. Health Economics, 10, 159174. Coast, J., McDonald, R., & Baker, R. (2004). Issues arising from the use of qualitative methods in health economics. Journal of Health Services Research and Policy, 9(3), 171176.

Cornwall, A., & Jewkes, R. (1995). What is participatory research? Social Science & Medicine, 41(12), 16671676. Dolan, P., & Cookson, R. (2000). A qualitative study of the extent to which health gain matters when choosing between groups of patients. Health Policy, 51, 1930. Donaldson, C., & Farrar, S. (1993). Needs assessment: Developing an economic approach. Health Policy, 25, 95108. Fals-Borda, O., & Rahman, M. A. (1991). Action and knowledge: Breaking the monopoly with participatory action-research. New York: Apex Press. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine. Greenwood, D. J., & Levin, M. (1998). Introduction to action research. Thousand Oaks: Sage Publications Inc. Guba, E. G. (1978). Toward a methodology of naturalistic inquiry in educational evaluation. Los Angeles: Center for the Study of Evaluation. Halma, L., Mitton, C., Donaldson, C., & West, B. (2004). A case study on priority setting in rural southern Alberta: Keeping the house from blowing in. Canadian Journal of Rural Medicine, 9(1), 2636. Hart, E., & Bond, M. (1995). Action research for health and social care: A guide to practice. Philadelphia: Open University Press. Institute of Health Promotion Research (IHPR) (2000). Guidelines and categories for classifying participatory research projects in health promotion. www.ihpr.ubc.ca.guidelines.htm Jan, S. (2000). Institutional considerations in priority setting: Transactions cost perspective on PBMA. Health Economics, 9(7), 631641. Lincoln, Y. S. (1992). Sympathetic connections between qualitative methods and health research. Qualitative Health Research, 2, 375391. Lomas, J. (1997). Reluctant rationers: Public input to health care priorities. Journal of Health Services Research and Policy, 2(2), 103111. Madden, L., Hussey, R., Mooney, G., & Church, E. (1995). Public health and economics in tandem: Programme budgeting, marginal analysis and priority setting in practice. Health Policy, 33, 161168. Marshall, C., & Rossman, G. B. (1989). Designing qualitative research. Newbury Park, CA: Sage. McDonald, R. (2002). Using health economics in health services. Rationing rationally?. Buckingham: Open University Press. Miles, M. B., & Huberman, A. (1994). Qualitative data analysis. Newbury Park, CA: Sage. Miller, P. (1997). Managing informed purchasing: A survey of decision makers. Journal of Management in Medicine, 11(1), 3542. Mitton, C., & Donaldson, C (2001). Twenty-ve years of program budgeting and marginal analysis in the health sector, 19741999. Journal of Health Services Research and Policy, 6(4), 239248. Mitton, C., & Donaldson, C. (2002). Setting priorities in Canadian regional health authorities: A survey of key decision makers. Health Policy, 60(1), 3958. Mitton, C., & Donaldson, C. (2004). Priority setting toolkit: A guide to the use of economics in health care decision making. London: BMJ Books. Mitton, C., Patten, S., Waldner, H., & Donaldson, C. (2003). Priority setting in health authorities: A novel approach to a historical activity. Social Science & Medicine, 57, 16531663.

ARTICLE IN PRESS
1134 S. Patten et al. / Social Science & Medicine 63 (2006) 11211134 Peacock, S. (1998). An evaluation of program budgeting and marginal analysis applied in South Australian hospitals. Melbourne: Center for Health Program Evaluation, Monash University. Stringer, E. T. (1999). Action research (2nd Ed). Thousand Oaks: Sage. Mitton, C., & Prout, S. (2004). Setting priorities in the south west of western Australia: Where are we now? Australian Health Review, 28(3), 301310. Patton (1990). Qualitative evaluation and research methods (2nd ed). Newbury Park: Sage.