Download Guide to Prioritization Techniques and more Exercises Public Health in PDF only on Docsity!
Guide to Prioritization Techniques
Introduction Despite the many accomplishments of local public health, we continue to see emerging population-wide health threats as we forge ahead into to the 21st^ Century. We are in an economic climate where LHD personnel are facing dire budget cutbacks while simultaneously dealing with issues like H1N1, chronic diseases, and natural disasters. Because LHDs are the backbone of the public health system, the recent movement to establish a national system of accountability for governmental health agencies is particularly timely. The Public Health Accreditation Board (PHAB) is developing a voluntary national accreditation program which is grounded in continuous quality improvement. As LHDs work toward meeting accreditation standards and implementing quality improvement efforts, they are faced with an infinite number of competing health issues to address, while keeping in mind several external considerations such as urgency, cost, impact and feasibility, to name just a few. Fortunately, a number of prioritization methods specifically designed to assist agencies with this very challenge have been developed and widely used in a range of industries including public health. When faced with these tough decisions, employing a defined prioritization technique can provide a structured mechanism for objectively ranking issues and making decisions, while at the same time gathering input from agency- wide staff and taking into consideration all facets of the competing health issues.
This document serves as a guide and provides five widely used options for prioritization including guidance on which technique best fits the needs of your agency, step-by-step instructions for implementation, and practical examples.
Getting Started Prior to the implementation of any prioritization process, preliminary preparations are necessary to ensure the most appropriate and democratic selection of priority health issues:i
1. Community assessment – Conducting assessments will determine the current status and detect gaps to focus on as potential priority areas. LHDs engaging in the Public Health Accreditation Board (PHAB) accreditation process must conduct a community health assessment (CHA) as a prerequisite for eligibility. A CHA provides data on the overall health of a community and uncovers target priority areas where a population may have increased risk for poor health outcomes. 2. Agency self - assessment - As part of the national accreditation process, LHDs must use the PHAB agency self-assessment tool to evaluate agency performance against nationally recognized standards. Post-assessment, LHDs can analyze their results and determine strengths and areas for improvement to address through continuous quality improvement efforts. Prioritization methods can be used to help select areas for improvement from a CHA or PHAB self- assessment. 3. Clarify objectives and processes – Before beginning the process, LHD leadership must ensure that all team members have a clear understanding of the goals and objectives along with the chosen prioritization process. 4. Establish criteria - Selection of appropriate prioritization criteria on which to judge the merit of potential focus areas is important to avoid selection based on bias or hidden agendas and ensure that everyone is ‘on the same page.’ Table 1.1 below identifies criteria commonly used in prioritization processes:
Table 1.1: Commonly Used Prioritization Criteriaii Criteria to Identify Priority Problem Criteria to Identify Intervention for Problem
Cost and/or return on investment Availability of solutions Impact of problem Availability of resources (staff, time, money, equipment) to solve problem Urgency of solving problem (H1N1 or air pollution) Size of problem (e.g. # of individuals affected)
Expertise to implement solution Return on investment Effectiveness of solution Ease of implementation/maintenance Potential negative consequences Legal considerations Impact on systems or health Feasibility of intervention
Prioritization in Practice The following section highlights five prioritization methods:
- Multi-voting Technique
- Strategy Grids
- Nominal Group Technique
- The Hanlon Method
- Prioritization Matrix
Each sub-section includes step-by-step instructions on implementation followed by examples illustrating practical application. It is important to remember that no right or wrong method of prioritization exists. Although the provided examples in this document are useful in gaining an understanding of how to use prioritization techniques, they are not meant to be prescriptive but rather, should be tailored to the needs of individual agencies. Additional information on prioritization processes can be found in the Assessment Protocol for Excellence in Public Health (APEX PH ).
Multi-voting Technique
iii
Multi-voting is typically used when a long list of health problems or issues must be narrowed down to a top few. Outcomes of Multi-voting are appealing as this process allows a health problem which may not be a top priority of any individual but is favored by all, to rise to the top. In contrast, a straight voting technique would mask the popularity of this type of health problem making it more difficult to reach a consensus.
Step-by-Step Instructions:
- Round 1 vote – Once a list of health problems has been established, each participant votes for their highest priority items. In this round, participants can vote for as many health problems as desired or, depending on the number of items on the list, a maximum number of votes per participant can be established.
- Update list - Health problems with a vote count equivalent to half the number of participants voting remain on the list and all other health problems are eliminated (e.g. if 20 participants are voting, only health problems receiving 10 or more votes remain).
- Round 2 vote – Each participant votes for their highest priority items of this condensed list. In this round, participants can vote a number of times equivalent to half the number of health problems on the list (e.g. if ten items remain on the list, each participant can cast five votes).
to healthcare services Red = Round 1 Elimination Green = Round 2 Elimination Blue = Round 3 Elimination
Strategy Grids
iv
Strategy grids facilitate agencies in refocusing efforts by shifting emphasis towards addressing problems that will yield the greatest results. This tool is particularly useful when agencies are limited in capacity and want to focus on areas that provide ‘the biggest bang for the buck.’ Rather than viewing this challenge through a lens of diminished quality in services, strategy grids can provide a mechanism to take a thoughtful approach to achieving maximum results with limited resources. This tool may assist in transitioning from brainstorming with a large number of options to a more focused plan of action.
The strategy grid below provides an example of an LHD’s effort to refocus efforts towards programs that will feasibly result in the greatest impact. Refer to the example strategy grid below while working through the step-by-step instructions.
Step-by-Step Instructions:
- Select criteria – Choose two broad criteria that are currently most relevant to the agency (e.g. ‘importance/urgency,’ ‘cost/impact,’ ‘need/feasibility,’ etc.). Competing activities, projects or programs will be evaluated against how well this set of criteria is met. The example strategy grid below uses ‘Need’ and ‘Feasibility’ as the criteria.
- Create a grid – Set up a grid with four quadrants and assign one broad criteria to each axis. Create arrows on the axes to indicate ‘high’ or ‘low,’ as shown below.
- Label quadrants – Based on the axes, label each quadrant as either ‘High Need/High Feasibility,’ ‘High Need/Low Impact,’ ‘Low Need/High Feasibility,’ ‘Low Need/Low Feasibility.’
- Categorize & Prioritize - Place competing activities, projects, or programs in the appropriate quadrant based on the quadrant labels. The example below depicts ‘Need’ and ‘Feasibility’ as the criteria and items have been prioritized as follows:
High Need/High Feasibility – With high demand and high return on investment, these are the highest priority items and should be given sufficient resources to maintain and continuously improve. Low Need/High Feasibility – Often politically important and difficult to eliminate , these items may need to be re-designed to reduce investment while maintaining impact. High Need/Low Feasibility – These are long term projects which have a great deal of potential but will require significant investment. Focusing on too many of these items can overwhelm an agency. Low Need/Low Feasibility – With minimal return on investment, these are the lowest priority items and should be phased out allowing for resources to be reallocated to higher priority items.
Strategy Grid
low Need high
Nominal Group Technique
v
The Nominal Group Technique (NGT) has been widely used in public health as a mechanism for prioritizing health problems through group input and information exchange. This method is useful in the early phases of prioritization when there exists a need to generate a lot of ideas in a short amount of time and when input from multiple individuals must be taken into consideration. Often, the Multi- voting Technique is used in conjunction with NGT whereby NGT can be used to brainstorm ideas and create a broad list of possibilities and Multi-voting can be used to narrow down the list to pinpoint the top priorities. One of the greatest advantages of using this technique is that it is a democratic process allowing for equal say among all participants, regardless of position in the agency or community.
Step-by-Step Instructions:
1. Establish group structure – Establish a group of, ideally, 6-20 people to participate in the NGT process and designate a moderator to take the lead in implementing the process. The moderator should clarify the objective and the process. 2. Silent brainstorming – The moderator should state the subject of the brainstorming and instruct the group to silently generate ideas and list them on a sheet of paper. 3. Generate list in round-robin fashion – The moderator should solicit one idea from each participant and list them on a flip chart for the group to view. This process should be repeated until all ideas and recommendations are listed.
Low Need/High Feasibility
Sixteen parenting classes in a primarily aging community with a low teen pregnancy rate
High Need/High Feasibility
High blood pressure screening program in a community with rapidly increasing rates of stroke
Low Need/Low Feasibility
Investing in health education materials in Spanish in a community with <1% non- English speaking population
High Need/Low Feasibility
Access to dental care in a community with a largely uninsured population.
high
Feasibility
low
department Engage policymakers and community to support health department initiatives 1 6 3 18 Promote understanding of public health in general and health department as an organization among stakeholders (may include internal and external stakeholders)
3 1 6 17
Better utilize data and best practices to inform health department program decisions and to generate community support and understanding of the health department’s role and contribution to public health
2 4 6 20
Establish a health department presence and recognition at a level comparable to other major City departments
4 5 5 27
The Hanlon Method
vi
Developed by J.J. Hanlon, the Hanlon Method for Prioritizing Health Problems is a well respected technique which objectively takes into consideration explicitly defined criteria and feasibility factors. Though a complex method, the Hanlon Method is advantageous when the desired outcome is an objective list of health priorities based on baseline data and numerical values.
Step-by-Step Instructions:
- Rate against specified criteria – Once a list of health problems has been identified, on a scale from zero through ten, rate each health problem on the following criteria: size of health problem, magnitude of health problem, and effectiveness of potential interventions. It is important to remember that this step requires the collection of baseline data from the community such as from a community health assessment. Table 4.1 illustrates an example numerical rating system for rating health problems against the criteria.
Table 4. The Hanlon Method: Sample Criteria Rating
Rating
Size of Health Problem (% of population w/health problem)
Seriousness of Health Problem Effectiveness of Interventions
9 or 10 >25% (STDs)^ Very serious (e.g. HIV/AIDS)^ 80% (e.g. vaccination program)^ -^ 100% effective
7 or 8 10% - 24.9% Relatively Serious 60% - 80% effective 5 or 6 1% - 9.9% Serious 40% - 60% effective 3 or 4 .1% - .9% Moderately Serious 20% - 40% effective 1 or 2 .01% - .09% Relatively Not Serious 5% - 20% effective
0 < .01% (Meningococcal Meningitis)^ Not Serious (teen acne)^ <5% effective (access to care)
Guiding considerations when ranking health problems against the 3 criteria
Size of health problem should be based on baseline data collected from the individual community.
Does it require immediate attention? Is there public demand? What is the economic impact? What is the impact on
Determine upper and low measures for effectiveness and rate health problems relative to those limits. For more information on assessing effectiveness of
quality of life? Is there a high hospitalization rate?
interventions, visit http://www.communityguide. org to view CDC’s Guide to Community Preventive Services. *Note: The scales in Table 1 are arbitrary models of how numerical scales are established and are not based on real epidemiological data; LHDs should establish scales that are appropriate for the community being served.
- Apply the ‘PEARL’ test - Once health problems have been rated by criteria, use the ‘PEARL’ Test, to screen out health problems based on the following feasibility factors:
P ropriety – Is a program for the health problem suitable? E conomics – Does it make economic sense to address the problem? Are there economic consequences if a problem is not carried out? A cceptability – Will a community accept the program? Is it wanted? R esources – Is funding available or potentially available for a program? L egality – Do current laws allow program activities to be implemented?
Eliminate any health problems which receive an answer of “No” to any of the above factors or proceed with corrective action to ensure that potential health priorities meet all five of the feasibility factors.
- Calculate priority scores – Based on the three criteria rankings assigned to each health problem in Step 1 of the Hanlon Method, calculate the priority scores using the following formula:
D = [A + (2 x B)] x C Where: D = Priority Score A = Size of health problem ranking B = Seriousness of health problem ranking C = Effectiveness of intervention ranking
*Note: Seriousness of health problem is multiplied by two because according to the Hanlon technique, it is weighted as being twice as important as size of health problem.
- Rank the health problems – Based on the priority scores calculated in Step 3 of the Hanlon Method, assign ranks to the health problems with the highest priority score receiving a rank of ‘1,’ the next high priority score receiving a rank of ‘2,’ and so on.
McLean County Health Department - The Hanlon Method Example: As a part of the Illinois Project for Local Assessment of Needs (IPLAN), a community health assessment and planning process, the McLean County Health Department (MCHD) used the Hanlon Method to prioritize health problems in the community. After determining the top eight health problems from the community health assessment data, MCHD used the Hanlon Method to establish the top three focus areas the agency should address. The following steps were taken to implement the prioritization process:
develop a new performance appraisal system which incorporated eight fundamental core competencies which all staff are expected to meet. The new system was tested and changes were made based on feedback provided from the staff. In an effort to continually improve the system, each center is developing more specific competencies for particular job titles.
Prioritization Matrix
iv
A prioritization matrix is one of the more commonly used tools for prioritization and is ideal when health problems are considered against a large number of criteria or when an agency is restricted to focusing on only one priority health issue. Although decision matrices are more complex than alternative methods, they provide a visual method for prioritizing and account for criteria with varying degrees of importance.
Step-by-Step Instructions: The following steps outline the procedure for applying a prioritization matrix to prioritize health issues. While working through each step, refer to Table 4.1 below for a visual representation:
Table 5.1: Example Prioritization Matrix Criterion 1 (Rating X Weight)
Criterion 2 (Rating X Weight)
Criterion 3 (Rating X Weight)
Priority Score
Health Problem A 2 X 0.5 = 1 1 X .25 = .25 3 X .25 = .75 2 Health Problem B 3 X 0.5 = 1.5 2 X .25 = 0.5 2 X .25 = 0.5 2. Health Problem C 1 X 0.5 = 0.5 1 X .25 = .25 1 X .25 = .25 1
1. Create a matrix – List all health issues vertically down the y-axis (vertical axis) of the matrix and all the criteria horizontally across the x-axis of the matrix so that each row is represented by a health issue and each column is represented by a criterion. Include an additional column for the priority score. 2. Rate against specified criteria – Fill in cells of the matrix by rating each health issue against each criterion which should have been established by the team prior to beginning this process. An example of a rating scale can include the following:
3 = criterion met well 2 = criterion met 1 = criterion not met
3. Weight the criteria – If each criterion has a differing level of importance, account for the variations by assigning weights to each criterion. For example, if ‘Criterion 1’ is twice as important as ‘Criterion 2’ and ‘Criterion 3,’ the weight of ‘Criterion 1’ could be .5 and the weight of ‘Criterion 2’ and ‘Criterion 3’ could be .25. Multiply the rating established in Step 2 with the weight of the criteria in each cell of the matrix. If the chosen criteria all have an equal level of importance, this step can be skipped. 4. Calculate priority scores – Once the cells of the matrix have been filled, calculate the final priority score for each health problem by adding the scores across the row. Assign ranks to the health problems with the highest priority score receiving a rank of ‘1.’
Lawrence-Douglas County Health Department: Example Prioritization Matrix
Prior to beginning the prioritization process, Lawrence-Douglas County Health Department (LDCHD) developed a decision-making team which was comprised of ten people including directors and coordinators from throughout the department. Next, upon completion of an agency self-assessment, LDCHD identified areas of weakness and created a list of three potential health indicators to improve upon, along with five criteria found to be most relevant in pinpointing which health indicator will prove to have the greatest impact on the needs of Lawrence-Douglas County. Once these variables were determined, the groundwork was in place and LDCHD was ready to use a prioritization matrix to weigh the identified health indicators against each criterion to make a final decision on a focus area for a QI project. The following steps were used to implement the process:
1. Create a matrix – LDCHD used the prioritization matrix shown in Table 4.2 , with the chosen health indicators listed on the Y-axis and each criterion listed across the X-axis:
Table 5.2: LDCHD Prioritization Matrix
Evaluative Criteria
Proposed Area for Improvement Based on LHD Self-Assessment
Linkage to Strategic Vision (.25)
Do we need to improve this area? (.25)
What chance is there that changes we put into place will make a difference? (.5)
Likelihood of completion within the timeframe we have (.5)
Importance to Customer (customer is the one who would benefit; could be patient or community) (.75)
Total Score
Media strategy & Communications to raise public health awareness
3 X (.25) 4 X (.25) 4 X (.5) 3 X (.5) 3 X^ (.75)^ 7.
Work within network of stakeholders to gather and share data and information
2 X (.25) 3 X (.25) 2 X (.5) 1 X (.5) 1 X (.75) 3.
Continuously develop current information on health issues that affect the community
4 X (.25) 2 X (.25) 3 X (.5) 1 X (.5) 2 X (.75) 5
*Note: The numerical rankings in Table 3.1 are meant to serve as an example and do not reflect the actual rankings from LDCHD’s prioritization process.
2. Rank each health indicator against criteria – Each member of the decision-making team was given this prioritization matrix and asked to fill it out individually based on the following rating scale: 4 = High priority 3 = Moderate priority 2 = Low priority 1 = Not priority
After completing the matrix, each team member individually discussed with the facilitators of the process the reasoning behind how the health indicators were rated.
3. Weight the criteria – Although LDCHD weighted each criterion equally, (i.e. each criterion was assigned a multiplier of 1) the numbers in red provide an arbitrary example of how an agency
Appendices
3 Round Multi-voting Template
Health Indicator Round 1 Vote Round 2 Vote Round 3 Vote
Instructions:
- Fill in items to be prioritized under the ‘Health Indicator’ column
- Tally votes for each round of voting in the respective column
Hanlon Method Worksheet
Instructions:
- Fill in items to be prioritized under the ‘Health Indicator’ column.
- Fill in the ‘A,’ ‘B,’ and ‘C’ columns with the assigned ratings for each health indicator with respect to the three criteria.
- Calculate the priority score using the formula in column ‘D.’
- Rank the health indicators with the highest priority score receiving a rank of ‘1.’
Health Indicator A Size^ B Seriousness
C Effectiveness of Intervention
D Priority Score (A + 2B)C
Rank
Prioritization Matrix
Health Indicator ______________ _______________ Priority Score
Instructions:
- Fill in items to be prioritized under the ‘Health Indicator’ column.
- Fill in the blank spaces in columns 2, 3 and 4 with the chosen criteria.
- Fill in the ranks for each health indicator under the appropriate criteria.
- Calculate the priority score by adding the rankings in each row.
