'Shared Challenge, Shared Solution' was a public engagement process using a Citizens’ Advisory Panel to provide recommended service changes to balance the Hospital's budget. The CAP's recommendations were accepted by the Local Health Authority without amendment.
Problems and Purpose
The Northumberland Hills Hospital (NHH), located in Cobourgh, Ontario, was facing Provincial Government funding cuts, and needed to make hard decisions about cutting Hospital services.
In August 2009, the Hospital Board initiated 'Shared Challenge, Shared Solution', a civic engagement process using a Citizens’ Advisory Panel (CAP) (also known as a Citizens' Reference Panel). The CAP was given the mandate to provide the Board with the public’s perspective on service changes that would help to balance the Hospital’s budget. NHH’s first Citizens’ Advisory Panel was a new way to work together to address tough problems. It brought together a group of community members, chosen at random through a civic lottery, to learn about the issues, represent the interests of their neighbours and fellow citizens, and make informed recommendations on service deliver at NHH and the Cobourg Local Health Integration Network (LHIN) that oversees the planning, integration, and funding of health care in the region.
Background History and Context
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Organizing, Supporting, and Funding Entities
Northumberland Hills Hospital (NHH) established a collaborative to support the Citizens’ Advisory Panel in its work, including the Hospital Board, providing governance oversight; external consultants from MASS LBP, with expertise in public engagement; researchers from Queen’s School of Business, with expertise in resource allocation decision making and program evaluation; and the Northumberland Community Futures Development Corporation, as funding partner.
Participant Recruitment and Selection
5,000 special envelopes were mailed to households chosen at random throughout west Northumberland. One in twelve households received a letter and an invitation to nominate one member of their household to volunteer to serve on the Panel. Current staff, volunteers or physicians with privileges at NHH were not able to participate, but their family members were allowed. Joining the CAP was a major commitment, requiring its members to attend five day-long Saturday sessions between late October and early December. Nevertheless, nearly one hundred residents volunteered. Ultimately, twenty-eight residents were selected during a random draw that ensured that the panel would match the age, gender, and geographic profile of the region. Sudden family events prevented three panelists from completing the program and they decided to withdraw their names.
Methods and Tools Used
The two methods used are characteristic of other participatory initiatives designed by MASS LBP: Civic Lottery and Citizens' Advisory (Reference) Panels. The Civic Lottery method allows for the selection of a representative sample while the CAP allows for in-depth learning, deliberation and decision making on one or more key issues. Similary to Citizens' Juries, the CAP method involves various tools of engagement including surveys, information and question and answer periods, small group deliberation (such as thematic dialogue tables or roundtables) and plenary discussion.
NHH's community engagement initiative was partly triggered by a requirement in the Local Health System Integration Act of 2006, which requires that Ontario's health service providers "engage the community of diverse persons and entities in the area where it provides health services when developing plans and setting priorities for the delivery of health services."
What Went On: Process, Interaction, and Participation
Five full-day sessions occurred between the end of October and the beginning of December. The Terms of Reference set out the purpose of the CAP: To provide advice to the NHH Board of Directors in their development of a contingency plan to bring the Hospital’s operating budget into a balanced position through service changes, in the event the Hospital is unable to balance through other means such as operating efficiencies and/or other revenues. Panelists heard from a wide range of health care experts, including doctors and community health care workers, and many staff from NHH, including the vice-president of patient services and the vice-president of finance. Panelists also completed many small-group activities that helped them to better understand the health care system and begin evaluating different service priorities. Together, the group worked with a values-based framework developed with the Board and internal stakeholders, such as front-line staff, volunteers, Foundation members, union representatives, and nurses, to develop four scenarios that would help to balance the Hospital’s budget by determining the Hospital’s core services. On their final day together, those four scenarios would become one as the panelists worked to reconcile different priorities and reach agreement on their recommendations for this report.
Day One : October 24, 2009
The first meeting began with a warm welcome. Twenty-seven panel members met one another, the facilitation team, and NHH staff. Each member was asked to explain why he or she had agreed to participate and what he or she hoped to achieve. Though they came from many different backgrounds, it was clear that they all had one thing in common: a shared concern for the Hospital.
After a short break the Hospital’s president and CEO, briefed the panelists about the Hospital’s financial situation, reviewed the Shared Challenge Shared Solution process, and discussed his determination to put NHH on a stronger financial footing. He relayed that the ministry and the LHIN wouldn’t hesitate to make choices for the Hospital if it didn’t reach a balanced budget on its own.
Next the panelists were presented with the draft framework they would use to evaluate the Hospital’s different services. This ‘values-based decision making framework’ was begun by the Hospital’s volunteer Board, and then refined to include input from physicians and frontline staff. It includes a set of values and principles for the provision of health care services at the Hospital. According to the framework, the panelists were to prioritize the Hospital’s services according to their alignment with six values:
- Community Needs and Responsiveness
- Effectiveness, Safety and High Standards
- Relationships and Public Trust
Following lunch, the panelists heard presentations from CEO of the Central East Local Health Integration Network (CE LHIN) and CEO & President of the Ontario Hospital Association. The CEO of CE LHIN spoke about the role of the LHIN, and how its decisions affect the Hospital and other health system providers in the region. The CEO & President of the Ontario Hospital Association shared with the panelists some of the big-picture challenges faced by the hospital sector — pointing out that NHH certainly wasn’t alone among Hospitals in Ontario. They also discussed his sense of how the hospital sector was evolving towards a clearer focus on providing acute care, with other health services being provided in people’s homes or by community-based organizations.
Day Two: November 7, 2009
The second day began with a guided, behind-the-scenes tour of the Hospital. Panelists had a chance to visit each department, examine equipment, including the MRI and CT machines, and speak with staff. In the afternoon, panelists heard from three speakers.
An epidemiologist and health consultant, provided important demographic details about west Northumberland. He described the current service demands placed on the Hospital, as well as projected trends concerning common diseases like arthritis, diabetes and high blood pressure.
Next, panelists heard from vice president of patient services and one of the physicians on staff at NHH. They described to panelists the broader context of the health system and how NHH works in collaboration with many organizations in the community. They also described each of the Hospital’s twenty-three main services — services which the panelists would be prioritizing.
Lastly, the Hospital’s vice president of finance and information services, took the panelists through a detailed reading of the Hospital’s budget, asserting that without action, NHH could quickly find itself facing major structural deficits that could jeopardize its ability to provide critical services.
Finally, the panelists formed groups to begin a series of exercises that would help them to become better acquainted with the range of services provided by the Hospital. With the support of the facilitation team, panelists ranked the services first by cost, then by volume of patients.
Day Three: November 14, 2009
For their third day together, the panelists moved from the Hospital to meet in the gymnasium of Port Hope Public High School. Later that day, the CAP would host a Public Roundtable Meeting that any member of the public could attend. Before the roundtable began, panelists spent the morning working in groups to determine how each service might correspond with the six values that were the basis of the decision-making framework. By lunchtime, each of the six values groups presented their spectrum of prioritized services and spent time discussing their choices. Shortly after lunch, members of the public began to arrive. Panelists greeted close to fifty members of the public as they sat down at more than two-dozen round tables — each of which focused on one of the six values.
NHH CEO welcomed the audience and providing a detailed account of the financial pressures faced by the Hospital. He stressed that this session was an important opportunity for the public to provide feedback, suggestions and recommendations to the panelists and to the Hospital.
Over the next ninety minutes, the panelists assumed the role of facilitators, listening and asking questions of the new faces that joined their table. The Roundtable Meeting gave the panelists another important perspective to consider in their deliberations.
Day Four: November 28, 2009
For the fourth session of the Panel, members reconvened at the Hospital. In the morning, they heard three final presentations before beginning their deliberations. The chief executive of the Central East Community Care Access Centre (CE CCAC), explained the role his organization plays in providing home care services throughout the region. More that 30,000 clients are supported by the CCAC on any given day, which he described as a “Hospital without walls”.
The executive director of the Port Hope Community Health Centre focused his remarks on how the Health Centre helps to provide primary care to area residents, and also works to promote healthy living. The Centre also runs several community-based programs, including the Walk this Way walking program, a diabetes education program, a support group for caregivers and distributing food from the Good Food Box program
Finally, panelists heard from the president of the Hospital’s medical staff. She shared the perspectives of her physician colleagues and the discussions they’d had concerning the Shared Challenge, Shared Solution process. As someone who has recently chosen the region as her home, she said she was very proud of NHH and the remarkable level of services it offers.
With the conclusion of the morning presentations, the panelists turned their attention to discussing the differences between the services offered at NHH. Each panelist was asked to take everything they had learned and rank the Hospital’s twenty-three services according to those they deemed to be most essential to the values, mission and future of the Hospital and those that were deemed least essential. Next they compared their lists with one another and found that generally they could divide themselves into four major clusters or groups.
Four new groups formed to discuss the similarities between their rankings. Over the balance of the afternoon, each group worked to name, describe and refine their rankings, which now became known as scenarios. The purpose of each scenario was to describe a plausible future for the Hospital that would include a different range of services.
By mid-afternoon, four distinct scenarios had emerged. They were named “Essential Services: Continuity of Care”, “Integrated Community Acute Care”, “Essential Services” and “Sustaining Our Strengths”. The four groups then proceeded to describe what their future Hospital would look like, as well as determining what services would support this vision. These four scenarios were then provided to the Hospital’s management team for their comments.
Day Five: December 5, 2009
The panelists reconvened for their final day with a sense of excitement and purpose. When they compared their four scenarios at the end of the Northumberland Hills Hospital Citizens’ Advisory Panel on Health Service Prioritization 12 fourth day, they realized their scenarios shared more in common than many had expected. Now it was time to see whether it was possible to bring the four scenarios together. During the course of the week, the management team had met to review each of the scenarios and provide technical advice regarding the feasibility of each proposal.
There was a short presentation that outlined the management team’s response to each scenario, and commended the CAP for the sophistication and plausibility of their proposals. With the benefit of the management team’s review, and clarification on a few remaining questions, the panelists began their final plenary session.
They paused to review each of the twenty-three services, before beginning a two-stage voting process to determine whether each service should be designated as a core or non-core service. Any health service that received fifteen or more votes from among the twenty-five delegates would be designated as core.
The first round of voting served as a method of identifying both clear consensus and areas of disagreement or concern. Seven services were unanimously voted core services in this round. A further ten services had received the fifteen votes required, and the eight services that fell below the threshold were referred back to the panel for further deliberation.
During deliberations that followed, panelists took turns speaking for why each of these eight were important to NHH’s future. In their comments, panelists drew on the values framework and the information they had learned to offer reasons why they believed the service was essential to meeting the community’s needs and interests.
An hour later, a second round of voting moved three of the eight noncore services back to the core list. Only five remained. Panelists also opted to place “asterisks” on several core and non-core services with specific advice they wanted to see communicated to the Hospital’s Board.
With their prioritization work complete, the panelists broke into four groups and turned their attention to drafting their report. Each group took on a specific task: detailing the vision for the future of NHH, reviewing the services that supported the vision, discussing the implications of their recommendations and applying the Ministry of Health and Long Term Care’s Framework for Making Choices, and finally providing NHH with a series of additional ideas and suggestions for consideration by the Board. These tasks corresponded to the responsibilities set out in the CAP Terms of Reference. By the end of the day, each group presented their work in plenary. Each panelist had a chance to respond and add personal comments or reflections.
The reports of each working group are collected as follows:
- A vision statement and preamble explaining the CAP’s vision for the future of the Hospital
- A rationale and explanation of the core services that were selected to support the CAP’s vision
- Recommendations concerning the transfer of non-core services to other health service providers, based on the ministry’s Framework for Making Choices
- Other recommendations and suggestions for the Board to consider
Panelists’ vision for Northumberland Hills Hospital is a community Hospital that:
- Focuses on providing high-quality acute care
- Lives by its values
- Strives for the fullest possible integration with community-based care providers
- Continuously engages the community and works to build trust
- Thinks long-term and takes into account new trends, technologies and the future needs of the community
Panelists agreed that in order to achieve this vision NHH should:
- Regularly evaluate the range of services it provides
- Engage community-based care providers as partners in providing services
- Ensure that all health services remain locally accessible
- Never compromise
Each service was evaluated on the basis of six values that were proposed by the Hospital’s Board and refined by Hospital staff and members of the CAP.
- Community Needs and Responsiveness
- Effectiveness, Safety and High Standards
- Relationships and Public Trust
Following a long process of learning and deliberation, panelists applied two service designations: Core and Non-core. The core service designation was defined as any health service that received fifteen or more votes from among the twenty-five delegates. Following a second round of voting, those services that received fewer than 15 votes were designated as non-core services. Panelists recommend that the Hospital retain its core services, and work towards divesting non-core services to other health providers according to the process laid-out in the Ministry’s Framework for Making Choices.
The following services were unanimously determined to be core services:
- Emergency Department
- Diagnostic Imaging: Computed Tomography
- Diagnostic Imaging: Radiology (X-Ray)
- Diagnostic Imaging: Ultrasound
- Intensive Care Unit
- Medical/Surgical Inpatient Acute Care
- Surgical Services (Operating Room, Day Surgery, Recovery)
The following services were also determined to be core services:
- Diagnostic Imaging: Magnetic Resonance Imaging (23 votes)
- Satellite Dialysis Clinic (20 votes)
- Diagnostic Imaging: Bone Mineral Densitometry (18 votes)
- Satellite Chemotherapy Clinic (18 votes)
- Community Mental Health Program* (18 votes)
- Diagnostic Imaging: Mammography (18 votes)
- Inpatient Rehabilitation (16 votes)
- Ambulatory Care* (16 votes)
- Maternal Child Care* (16 votes)
- Fast Track Service (16 votes)
- Diagnostic Imaging: Nuclear Medicine* (15 votes)
The following services were unanimously determined to be non-core services:
- Complex Continuing Care*
- Interim Long Term Care* Northumberland Hills Hospital Citizens’ Advisory Panel on Health Service Prioritization 16
- Diabetes Complication Prevention Strategy Clinic*
These services were also determined to be non-core services:
- Palliative Care Service* (8 votes)
- Outpatient Rehabilitation Service* (2 votes)
With the presentations complete, the lead facilitator asked the group whether they agreed to ratify their draft report for submission to the board. The vote was unanimous. And with a sense of accomplishment and relief, the room broke into applause. It was time to adjourn. But before the panelists left, organisers from NHH took a moment to express their gratitude for the panel’s efforts and dedication. One by one the panelists were presented with a certificate of public service and a group photograph was taken in the Hospital’s atrium to commemorate their work.
Influence, Outcomes, and Effects
Shared Challenge, Shared Solution was designed to help develop a plan to place NHH's finances back on sound, long-term footing while retaining trust in the hospital as a valued public institution in west Northumberland that was worthy of ongoing and active donor and volunteer support. It did just that.
The CAP process brought together personal experience, expert knowledge, and public context to give Panel members the insights that they needed to translate their opinions and ideas into meaningful and credible recommendations for the hospital Board. It respected the hospital's commitments to be proactive, transparent and inclusive. The communication before, during and after the CAP kept the broader public informed and highlighted avenues where everyone could, if they desired, become involved.
The LHIN accepted the Board's proposed service changes without amendment. Implementation of that plan, which involved the closure of several programs, began immediately. As a result of these efforts, on March 31, 2011, NHH achieved its first balanced operating budget in years, and it is on track to sustain the same balance in 2011/2012. Donations, as measured by local participation in ongoing Foundation and Auxiliary fundraising events, have grown or held steady, indicating continued trust in the organization.
In April, 2010, the Hon. Deborah Matthews, Ontario's Minister of Health and Long-TermCare, praised the NHH project as "innovative" during a statement in the provincial legislature, and she encouraged other Ontario hospitals to consider NHH's approach when seeking ways to engage the public:
The Citizens' Advisory Panel [is] something that I think other hospitals may wish to explore because it does actually ask the people in the community what they need to protect and what could be done better outside the hospital.
On Tuesday, March 1, 2011, The Globe and Mail featured an article highlighting NHH's "novel approach of creating a Citizens' Advisory Panel on Health Service Prioritization…."
In NHH's 2010 accreditation report, Accreditation Canada acknowledged NHH's community engagement practices as an area of strength:
The NHH is embarking on a transformation journey. It has engaged the community in a meaningful manner with respect to service provision, given its financial imperatives. The community advisory panel, along with perspectives from other stakeholder groups, were considered in the organization's new draft strategic plan and submission of the 2010/2011 operating plan.
Analysis and Lessons Learned
The CAP process was audited and evaluated by researchers from The Monieson Centre at the Queen's University School of Business. As part of this process, panelists completed a total of eight surveys: one after each of the five sessions, a pre-survey, and two post-CAP surveys. This evaluation not only provided NHH with information for future community engagement processes, but it also enabled facilitators to modify sessions as they received Panel member feedback following each CAP meeting. Baseline, mid-stream and post-event evaluation tools are strongly recommended for organizations planning public engagement, regardless of the participation method selected.
Clear communication around the organization's expectations of participants at the beginning of the exercise is also recommended. In the early stages of planning for the CAP, a detailed Terms of Reference was prepared to outline the roles and responsibilities of the CAP, their reporting relationship, and most importantly, the scope of their mandate. This document, developed in consultation with the NHH Board and senior management team, was made available on the hospital's website at nhh.ca, and it was essential to the CAP's success.
The 185-page evaluation report delivered to the NHH Board from Queen's University concluded that NHH "went far above and beyond the minimum requirements for public consultation" and achieved its goal of engaging the community. Before the CAP, 43% of the panelists were satisfied with NHH's method of making decisions about services; this jumped to 83% in the post-CAP survey.
The members of the CAP recognized the significant commitment of the CEO and NHH's Senior Management Team, and they greatly appreciated the hospital's willingness to listen and share information. Survey comments praised NHH's overall facilitation of the CAP, saying the sessions were well organized, the overall curriculum and format were effective, and the facilitators were unbiased. Of particular interest is the fact that the panelists unanimously agreed that NHH should continue to use the CAP model to obtain public input. Given the chance, 92% of the members would participate in a similar process, and 96% felt they had accomplished something important.
 Biron, R., and Gillard, J., 'Case 6: Shared challenge, shared solution: Northumberland hills hospital's collaborative budget strategy', in Citizen Engagement in Health Casebook (Online: Canadian Institutes of Health Research, 2013), http://www.cihr-irsc.gc.ca/e/47593.html
  Biron and Gillard, 'Case 6: Shared challenge, shared solution: Northumberland hills hospital's collaborative budget strategy', http://www.cihr-irsc.gc.ca/e/47593.html