What constitutes high performance in priority setting and resource allocation? Decision maker narratives identified from a survey and qualitative study in Canadian healthcare organizations

Abstract

Priority setting and resource allocation are key management functions; however, there may be different understandings as to what makes for a high-performing organization in this area. To interpret how decision makers actually approach this question, our research looks at what might contribute to one’s reputation as such. Two sets of qualitative data are used. Senior healthcare leaders were asked to nominate organizations which they considered high performers in priority setting and resource allocation and to justify their choices. This open-ended question was analyzed to identify themes. Rigorous process was most often cited. Six case studies were subsequently conducted; respondents were asked to comment upon why they thought their organization might be named by others as a high performer. These replies were analyzed qualitatively to identify prominent storylines: three distinctive narratives are summarized here. These help us to understand how organization leaders in particular contexts bring together stakeholders to pursue locally appropriate strategies for achieving contextually defined high performance.

Keywords

Canada case studies performance priority setting qualitative research resource allocation

Introduction

Setting priorities and allocating financial resources to support the achievement of these are among the most important tasks that health system managers are called upon to undertake. Demand for services can always outstrip the funds at hand. Therefore, models of good management practice call for monies to be spent efficiently, in line with best available evidence, to achieve the greatest benefits for patients and populations. In the Canadian healthcare system, these senior managers oversee publicly funded hospitals and regional authorities. Such structural arrangements require them to answer to their funders (provincial governments) with regard to their performance. Patients and the public too are demanding greater transparency and accountability. Similar circumstances prevail in many other public healthcare systems as well.

Academic research into priority setting and resource allocation (PSRA) processes has begun to accumulate in Canada and elsewhere. For instance, barriers and facilitators to formal priority setting have been identified.¹ Certain technical aspects, such as developing criteria and how to balance among them using decision analysis techniques have been investigated in some depth.^2–4 Characteristics of “fair” process have been enumerated.⁵ In addition to the published research, healthcare managers likely also turn for guidance in how to improve their resource allocation practices to their peers who carry out these tasks well.

Policy makers are busy with day-to-day pressures. Practical concerns incline them, if they take the time for comparative inquiry, to pay more attention to what appears to work, not academic reasons for what is and is not transferable and why.⁶ (p.333)

Yet, there are few substantive evaluations of healthcare priority setting processes or their results.^7,8 Thus, our preliminary investigation is about what grounds senior managers might look for when casting about to identify exemplars. We also have the opportunity to pair this with data about what some supposedly high-performing organizations might perceive to be the visible signs demarcating their achievement. The significance of this is to provide a rounded look, inside and out, at what Canadian healthcare leaders see as high performance. It will help to solidify our understanding of what to look for when we seek out those from whom PSRA practice should take its cues.

The data in this paper are derived from a three-year Canadian Institutes of Health Research-funded study; ethical approval was granted by the UBC Behavioural Research Ethics Board. It included a survey in which senior healthcare leaders in Canada nominated and justified organizations they considered “high performers” in this area, along with reflections from prospective high-performing organizations as to why they may have achieved notice among their peers. The dataset illuminates features that are perceived to constitute good practice. We employ established qualitative techniques to understand how the notion of high performance is constructed in, by and about organizations.

In the following sections of the paper, we first briefly describe our methods. We then report (i) what respondents to a cross-Canada survey said when asked to nominate organizations they saw as potential “high performers,” and (ii) qualitative evidence from Canadian case study sites, in which respondents reflect upon why their organizations may be perceived by others as high performers. We synthesized the latter into organizational narratives. The Discussion and Conclusion note a seeming disjunction between these two types of data. The former suggest what aspects of organization performance are attended to by outsiders, while the narrative data suggest what managers within healthcare organizations do to promote efforts to achieve high performance. The construction of performance stories is intimately bound to the implementation of particular PSRA practices. Understanding high performance requires consideration of both forms of knowledge. The organizational narratives which we identify point out the challenge in assuming that features of high-performing organizations can be readily transferred across contexts.

Methods

We conducted a national on-line survey of senior managers in Regional Health Authorities, or their closest equivalent, in all Canadian provinces and territories. Contact names and email addresses for senior executive team members were obtained primarily from publicly accessible websites; we were able to obtain information for 81 of 89 organizations. We sought three responses from each organization, representing vice-presidents with responsibility for finance, operations, and planning functions (as categorized by the research team). If initial contacts declined or did not respond, they were replaced by other names until three responses were achieved or no further names were available. The survey took place during the first four months of 2011. (Detailed information about the survey process is reported elsewhere).⁹

Survey questions asked about current PSRA practice (results are reported elsewhere).¹⁰ At the close of the survey, respondents were requested to nominate “high performing” organizations—based upon their own understanding of this term—and to give reasons for their selection. We noted these reasons and analyzed them inductively to identify key themes; these data, previously unpublished, are reported here. The total number of usable responses was 92—60 healthcare organizations, or two-thirds of all those approached, were represented by one or more respondents, and the response rate among managers contacted was 24%.

Subsequently, in-depth case studies were carried out with six healthcare organizations across Canada which could be potentially considered “high performers.” Cases were purposively selected from among those recommended in the survey phase, those suggested by an expert advisory panel of healthcare chief executive officers (CEOs) and from consultations with research team members. Such reputational sampling is useful when no sampling frame exists. Sociologists and political scientists have long used such methods, since at least the days when local leaders and powerbrokers were identified in community power structure studies.^11,12 In our study, we were seeking organizations of high repute. We note this is in line with Baker et al.’s¹³ approach to identifying cases for their international research into high-performing healthcare systems.

Diversity was achieved by sampling from different parts of Canada and by including sites with small and large budgets in urban and rural settings. Case study data included interviews or focus groups with 62 senior management team members, middle managers, and Board members. We worked with a key contact in each organization to develop a list of informants encompassing members of all three groups. The main aim of this phase was to build a grounded definition of the concept of high performance in PSRA. Respondents were also asked to comment on why they thought their organization might be seen by outside observers as a high performer. These sections of the transcripts were extracted and analyzed qualitatively to identify narratives of high performance; these data also have not been previously used in any publications related to this project.

Narratives constitute “an ordered and meaningful representation of events.”¹⁴ (p.172) They are stories of personal and collective experience which allow individuals and groups to make sense of occurrences in their environment. Narratives can be held implicitly or deliberately articulated and promoted. In the latter case, they “organiz[e] attention, practically and politically, not only to the facts at hand but why the facts at hand matter.”¹⁵ (p.195) Such narratives are “disseminated toward a preferred policy outcome.”¹⁶ (p.539) In other words, they attempt to frame perceived problems or challenges in such a way that the story leads to a compelling conclusion around which stakeholders can rally and act. Some public management scholars have used narratives as the basis for research into healthcare organizations’ performance. For instance Borins¹⁴ studied finalist submissions to the Innovations in American Government Awards and identified a dominant innovation fable. In the UK, interview research with senior healthcare managers has found narratives related to restructuring processes¹⁵ and leadership autonomy.¹⁸ However, there has been almost no study to date of the creation and use of narratives about healthcare priority setting or resource allocation (for an exception, see Robinson et al.).¹⁹ Our study thus adds to the literature by using an alternative means to understand how health system managers understand and apply PSRA techniques.

Results

First, we report what senior leaders said in the on-line survey when asked to nominate potential high performers and give reasons for their suggestions. Sixty five out of 92 managers responded to a question asking them to nominate “high performing” organizations when it came to PSRA, using whatever meaning they understand that term to have. Thirty nine of these respondents either were unable to name any organizations or were certain that there were none which could be so described. That is, they gave such comments as

“I don’t know all the organizations well enough to be able to comment.” [translation from the original French]

“I do not know of anyone doing this right.”

“When I hear of one and visit to kick tires to validate, have never come to conclusion of high performer.”

Twenty six participants were prepared to nominate one or more organizations, including their own; 27 organizations were named with six organizations receiving multiple mentions. Twelve individuals nominated their own organization (11 nominees in total), seven nominated other organizations within their province (eight nominees in total), and 11 nominated organizations from a different province (14 nominees in total). Twenty three gave reasons to justify their nominations. These reasons can be grouped into common themes (see Table 1). The number of codes exceeds the number of respondents, as some gave multiple justifications for their nominees. The most common rationale was the existence of formal processes: high performers were thought to do things in a way that was explicit and rigorous. Other themes among respondents’ answers include the linking of processes to outcomes; ability to use resource allocation to foster change; stakeholder engagement; and making resource allocation decisions with an explicit ethical lens. Relatively few respondents argued that balancing budgets was in itself evidence of high performance.

Table 1.

Reasons why senior managers identified healthcare organizations as high performers in PSRA.

Theme	Number of times mentioned	Illustrative quotes from on-line survey
Existence of (formal) processes	15	“Their framework is quite comprehensive and quite specific, with respect to values, aims, evaluation criteria, processes and timeframes.”
		“Have evidence based processes and clear decision-making criteria in place to validate allocation decisions.”
		“Link allocation to strategy in a clear and transparent way.”
Evidence of meeting goals/achieving results (overall, or in specific areas)	8	“Allocation of financial resources is based on both measurable performance and impacts on the health of the population. … I’ve never seen another model that takes into account both outputs and results.” [translated from the original French]
Resource allocation enables change or demonstrates innovation or flexibility	4	“[Organization has] a process that fosters innovation, changes and improvement.”
	4	“Ability to change programs and services.”
PSRA is carried out with notable stakeholder engagement	4	“The allocation method has been in place for many years; the method is rigorous and was agreed in conjunction with the health institution stakeholders.” [translated from the original French]
PSRA is carried out with notable stakeholder engagement	4	“Building processes and methodologies in house and with participation of many diverse internal stakeholders.”
Allocations are made with explicit attention to their ethical or value basis	3	“[Organization has] a process of determining value associated with resource decisions, has a basis in ethical decision-making and is open/transparent.”
Organizations consistently generate year-to-year balanced budgets or surpluses	2	“All but one year since regionalization, this organization has maintained a small surplus budget despite [Province] not providing the appropriate level of funding.”

PSRA: priority setting and resource allocation.

In addition to the substantive rationales described above, our data also suggest that those being seen as high performers may be those with high profile, e.g. in the media, in presence at conferences, represented on provincial or national Committees, etc. Some survey respondents, for instance, gave reasons such as, “based on a presentation that was given to us by their CEO” or “They are explicit in their processes and demonstrate buy-in from middle management and staff as evidenced by their ability to talk about allocations at national meetings. They distribute good material outlining their processes.”

Next, we examine case study data. Respondents were asked to reflect upon why their organizations might be perceived by outside observers and peers as high performing in PSRA. We report on three compelling narratives which emerged. Each of these narratives is strongly held within one of the study sites, an academic health centre, regional health authority, and planning and financing entity, respectively. That is, basic features of each organization’s storyline appear prominently across interviews from a range of internal stakeholders.

The first narrative is the “redemption story” (we were once so bad, we had to do something, and look how far we’ve come). We see this particularly in case site D; the quotes which follow demonstrate that this narrative is shared among many different informants from multiple locations within the organization. “From my perspective, I think it's the fact that we went from being so over budget to being now a leader and being seen at least in the province if not elsewhere as being … the best.” [D-12, middle manager focus group]

We have a, I guess, a history on our site. We were, kind of like, a -- not a swear word, but, kind of like, a joke at one point when we’re going through our problems. It was a sort of eye-rolling thing. But, what’s happening there now, you know, big deficit, CEO fired, it’s a kind of thing that other -- maybe the CEOs in other hospitals think, “There but for the grace of God go I”. … so people feel there’s been a turnaround. They like stories like that. All of us relate to stories where they’ve improved. [D-4, senior manager interview]

In ’99 and 2000, heading into 2001 when we had all those issues and supervisor, there probably wasn’t an organization in the province that didn’t know about it, in this province. And there probably wasn’t any major organization across the country that’s a big academic organization that didn’t know that, you know, [we were] at the bottom of the pit. So, that’s the pro and the con. The con is you’re in a pit. The pro is everyone sees it. But, as you start to rebuild, everybody else starts to see you rebuilding and heading in the right direction … . Over time what happens is you start to build and as you do that you’re able to tell a story of where you came from to where you are. [D-9, senior manager interview]

Our initial financial difficulties were very public knowledge [laughter], so the fact that that turned around, I think, was noticed by a few individuals and organizations … . I think we can even add that we had public senior management difficulties with our previous CEO, and there was a lot of dirty laundry that was aired in public. We started from a very low point. [D-13, middle manager focus group,]

Efforts to implement more rigorous approaches to PSRA are catalyzed by an environment of crisis, the “burning platform.”

I think you need a crisis. If you want to change, sometimes you do. … That happens a lot, I think, in maybe not a lot of industries but certainly in ours (D-6, senior manager interview). Circumstances helped us out. You had everyone realize that the ship was burning and you had to put out the fire or jump in the water.

So people’s attention was focused (D-4, senior manager interview).

The second narrative claims that organizations might be seen by their peers as high performing when they seem to achieve results in the face of known significant challenges and perceived relative lack of support—a “hard-done-by” story. We see this narrative particularly in interviews from case site A, where respondents point to the challenge of meeting the needs of a rapidly growing population. The demographic data to support claims about the magnitude of the challenge would be readily available to outside observers. Again, we present multiple quotations to show that the narrative is widely shared among informants here.

It is speculation, but I think that there's a fairly widely-held view that [our organization] has got some unique set of circumstances that are related to substantial population growth and resourcing that has not kept up with that population growth. And that's been true for many years. That's not just in the last fiscal year. And so, given that that has been the case, I think people would come to the conclusion, well, [we] must be doing something to squeeze more blood out of the stone and make better decisions and make better use of resources. Otherwise, you know, there would have been a lot more sort of adverse consequences. [A-3, senior manager interview]

[We], I think, [have] a bit of a reputation for always whining about not having enough money, so perhaps that's it. We have a growing and aging population and not enough money to meet the needs of same. So perhaps people think that we're constantly trying to kind of redesign and reallocate and squeeze every nickel out of every dollar that we get, that we maybe have something figured out as to how to do more with less. [A-4, senior manager interview]

We have had and continue to have significant growth in the population we serve, and so looking at the resources we have, trying to balance the demand with the resources we have available. So we have had to make some very difficult decisions earlier on [than other organizations]. [A-5, middle manager interview]

The third narrative tells a story of a funding and coordinating agency engaging with its stakeholders and partners in creating an equitable distribution of resources across service providers, including hospitals, community health centres and public health—a story of “system-thinking.” Cooperation and collaboration are behavioral traits central to decision makers’ actions here. “I guess what characterizes us as an organization is our level of partnership with the [provider] institutions. We are an agency that works a lot with the healthcare providers; we negotiate, we speak to them.” [F-2, senior manager interview; translation from the original French]

Well, I think that the highlight, the main reason is our culture of consultation. We work with provider organizations, we don’t do it ourselves. There are structures and processes in place which allow for dialogue, which make it possible to have all the right people at the roundtable … . I think that all the providers are looking for solutions, to take decisions which are for the common good. I believe that it’s maybe this aspect which distinguishes us from the other regions. [F-3, senior manager interview; translation from the original French]

First of all, it is that, we are very transparent. That helps a lot. We are forward-thinking. We have methods for making equitable allocations, and we listen to the stakeholders, we listen to them a lot. [F-5, senior manager interview; translation from the original French]

While the three organizations described above each presents a different orienting narrative with respect to their performance in PSRA, we should note that elements of the narratives appear across multiple sites as well. For instance, we see the redemption story identified in the history of at least two other sites.

We have had a dramatic turnaround fiscally … . We were on the verge of bankruptcy. And we've had a decade of balanced budgets and sort of turning the organization around fiscally. So I think that is also something that's really contributed to our reputation. [B-2, senior manager interview]

We’ve made some good progress. … . The organization has stabilized. It's gone from being one that was in the media a lot and been very critical of to one now that is becoming a leader. [E-6, senior manager interview]

Discussion

It seems that Canadian healthcare managers can identify few peer organizations that they would consider to demonstrate high performance when it comes to PSRA. Over 70% of respondents in a national survey when asked to nominate a health organization either declined to respond or explicitly denied that they knew of any such thing. Only a tiny number of organizations were mentioned more than once.

Still, valuable information could be gained from closer study of PSRA practices within candidate sites. As in any organization, members of healthcare provider systems develop stories—narratives—about why they are who, what, and where they are. Organizations do not have a single story, just like they do not have a single culture, but some stories are widely shared among members. We have described three such narratives of high performance in PSRA here. Narrative 1—the redemption story—reflects the historical circumstances in one of our case study sites, and it has significant power especially among those who lived through the tough times, when they were standing on the metaphorical burning platform. Such a story seems constructed largely for internal consumption. Through it, all are reminded of how much better the workplace is now than before, how hard-won stability allows for more resource allocation options in the here-and-now. Regardless of role, all employees are encouraged to work towards current goals which are far more aspirational than mere survival. “The story is a tool of engagement … in the construction of the reality that the story opens up.”²⁰ (p.36) Interviewees in this organization consistently spoke about the importance of such top-to-bottom alignment. Resource allocation is emphasized here as a systematic way to devote dollars both to daily operation and to moving the organization forward in key strategic areas of advantage.

Narrative 2—being hard-done-by—speaks to circumstances visible to organization managers which they believe set them apart from other provider authorities. These difficult circumstances are not adequately recognized and compensated by the provincial Ministry. In contrast to the first case, this narrative seems largely directed toward external audiences. Media coverage confirms that it is explicitly promulgated by the senior leadership. The villain in the story is clear: an unresponsive provincial government. Managers at all levels of the organization are heroically holding things together as best they can. PSRA processes must be designed to cope with these strains and need to be the best they can be in order to wring maximum value from each precious dollar. Circumstances offer the opportunity for them to demonstrate their creativity, but also perhaps to absolve them of responsibility should high performance not be achievable.

Narrative 3—system thinking—shows the pride which organizational leaders take in efforts to achieve active buy-in and support for resource allocation from a range of community partners. This narrative is directed both internally and externally. It articulates attitudes and values which agency personnel should embrace. It is also meant to tell external stakeholders what they should expect from this organization. Such a narrative self-conception makes considerable sense for this agency in its provincial context, where its assigned role is to contract with and allocate money to independent providers. Since it does not deliver services itself, this organization cannot directly achieve its goals for population and patient health improvement. Buy-in from external partners to a collaborative approach would seem to allow for greater performance to be achieved, with less dissent in respect to how funds are divided among providers with many different service mandates. The narrative here seems designed to facilitate such mutual understanding among the respondents, other members of their agency and the larger system of health organizations.

It seems narratives can derive from both historical and contemporary circumstances. Narrative 1 is based upon events which happened nearly 10 years before our research and in the context of the creation of the organization from merger of four predecessor entities. Overcoming of these early challenges still appeared to define local identity and culture. In the other cases, the narratives reflect more contemporary circumstances and present how these two organizations understand the current environment and expectations on them. We are unaware of anything in the history of these sites comparable to the traumatic shocks experienced by the first site; we might speculate that this is a factor in how the predominant narratives are linked to unique contexts but more research would be required here.

There appears to be relatively limited overlap between the survey data reported above and the organizational narratives. This tells us that while narratives are powerful tools for motivation and can account for why and how organizations have pursued high levels of performance, outside observers tend to focus on observable process features. They do not necessarily pay attention to evolution over time and how organizational processes have been deliberately put together in ways which effectively advance change. Observers might seize upon particular structures, mechanisms and processes from high-performing organizations and attempt to transfer and replicate them elsewhere. A study of organizational narratives suggests that this is not so simply done. The features which might characterize high performers need to make sense in context; enabling managers and providers to make sense of their own organizations’ PSRA processes is the work that narratives perform. As Robinson et al.²¹ note, crafting compelling narratives of change is a key leadership task.

The focus of this paper is not on what “objectively” makes a high performer; different organizations will draw on their own histories and cultures to seek the measures which would be locally credible. Rather we analyze what contributes to one’s reputation as such. Those with reputation are likely to be those whose advice is sought and whose efforts are emulated; we would hope that such organizations have undertaken the self-reflection and assessment needed to give their practices solid grounding.

This paper belongs to the larger body of literature which analyzes qualitative materials in terms of discourses,^22–24 or the meanings that human actors collectively construe from their experiences and situations. Narratives, metaphors, rhetoric, and frames are all devices through which discourses can be revealed.²² The study of such meaning-making has practical value in helping illuminate why, in particular contexts, certain policy and program choices are prioritized or become blocked. Our research could usefully be complemented with other studies drawing upon this family of techniques; we could imagine, for instance, that rhetorical analysis²⁵—looking at how the conceptions of high performance are used in an argumentative fashion to mobilize internal and external stakeholders toward some desired set of actions—may provide additional insights.

Limitations

Our study was limited to organizations with reputations as high performers; it is important to remember that there may be excellent work happening in organizations which do not have high public profile. Our questions also asked case study participants to provide an explanation for something they may have been unaware of or not considered previously; the method “requires post-hoc rationalisation, whereby the narrator seeks to explain what might have been diffuse and disparate influences”¹⁷ (p.927) and to link together motives and actions in a way that retrospectively makes sense. The consistency of stories generated in this way does tell us something about the beliefs which are shared among organizational members. Since case site organizations were involved in the selection of informants, we may not have had access to disconfirming points of view; this limits our ability to also identify and explore possible “counter-narratives” which might exist within organizations in competition with those which we did hear. Finally, the questions asked in the case study were not designed initially with a formal narrative analysis in mind, so we were unable to use all the techniques associated with that qualitative tradition; the descriptions are more “thin” than may be desired. Yet, they should be a starting point to consider the kinds of stories that health system managers can use in different contexts to mobilize internal efforts to improve practice.

Conclusion

We argue that it is not only quantifiable facts about performance, but how these are woven into organizational narratives, that affect the ways in which health provider systems attempt to tackle challenges and improve their ability to set priorities and allocate resources. Narratives tell us much about the ways in which change actually occurs. The creation and adoption of a checklist of “best practice” features, or copying processes used among reputed high performers, may not be enough to help healthcare organizations improve their resource allocation efforts. Healthcare provider systems need to build their own stories to mobilize collective efforts, and to provide reasons for why it is worth the effort to adapt the organization to such new mechanisms, behaviors, and values. Our research helps validate and brings greater attention to this key leadership role (Table 2).

Table 2.

Summary of findings and implications for managers.

Summary

• This research looks at how Canadian healthcare managers define high performance in priority setting and resource allocation

• We identify both those features which external observers use to nominate potential “high performing” organizations, and those features by which internal stakeholders would account for any reputation they may have obtained for leading priority setting and resource allocation practice in the Canadian healthcare system

Implications

• Performance narratives are an important means by which organizational leaders build internal and external support for priority setting and resource allocation policies

• Effective leadership can cultivate narrative claims which best resonate with organizational history, experience, and culture

Footnotes

Acknowledgments

The overall research project from which this material derives benefited from important contributions from Alan Davidson, Francois Dionne, Cam Donaldson, Jennifer Gibson, Stuart MacLeod, and Stuart Peacock. Translations from the French were generously provided by Dr Gregory Moullec.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This research was funded by the Canadian Institutes of Health Research (CIHR) under the Partnerships for Health System Improvement Program.

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