Fiducia dei cittadini e valutazione della performance nella sanità italiana - Una sfida aperta

Collana “Creare un valore nella sanità pubblica

Managing gaming phenomena in the Tuscan performance evaluation system.

The problem of gaming in performance evaluation systems is a known phenomenon (Bevan, 2006, Bevan Hood, 2006) that can take place especially when there are economic incentives related to specific targets. In all Tuscan Local Health Authorities (LHAs) and Teaching Hospitals (THs) a multidimensional performance evaluation system has been adopted since 2005, based on administrative and non-administrative data benchmarking. The goal of the Tuscany performance measurement system is to give a general outline for the management of the LHAs and THs, both for evaluating performance and for enhancing and promoting the results of the healthcare system. The performance evaluation system consists of 130 indicators classified in six dimensions: Population health assessment; Regional health system; Quality; Patient satisfaction; Staff satisfaction; Efficiency and financial performance After three years of the performance evaluation system’s adoption, integrated with an incentive system, improvements were achieved in most of the indicators monitored. The paper reports the effects of the performance evaluation system and how gaming phenomena were managed with a special focus on data manipulation. Methods The research team focused the analysis on the larger performance improvements during the years 2005-2007 to evaluate whether gaming phenomena have been taking place. The findings of this analysis were reported and discussed with top managers and professionals through individual interviews and group meetings in order to detect the determinants of the results obtained. In 2007 LHAs and THs whose indicators clearly show large improvement were highlighted during meetings with the top management asking them how his/her organization reaches its results. Results Gaming has been found in indicators concerning small and specific areas, such as the rate of hospitalization for heart failure, while indicators that concern larger phenomena, such as the pre-surgical length of stay, were less involved. The request of evidence to explain the improvement obtained has been a deterrent to gaming behaviors. Conclusions The results suggest that further development is needed to analyse suspicious cases. The public presentation of data and the request for evidence to explain large improvements in peer review meetings ease the accountability process. In addition these can be a deterrent for future activities.Gaming phenomena, Health service improvement, reputational level

Evaluating Performance in the Tuscan Health Care System.

The Tuscan health care system strives to foster cooperation among the various organizations that provide services. Government authorities therefore believe it is important to plan and develop a transparent system capable of monitoring the economic results of the region’s 16 public health authorities and their ability to pursue and accomplish the aims of the regional health care plan. The principal aim of the Tuscan performance evaluation system is to give a general outline of the management of the region’s health care authorities. This outline is intended to be useful both for evaluating performance and for enhancing and promoting the results of the healthcare system.Performance evaluation system, benchmarking in healthcare.

Designing performance measurement systems in health care: multiple organizational players and their interaction in the case of the prevention services in tuscany.

The designing of a performance measurement system usually involves several players, the number and the role of the players in building new performance measurement tools depending on the features affecting the type of organization. Among them, health care units can be considered as some of the most complex to manage (“Running even the most complicated corporation must sometimes seem like child’s play compared to trying to manage almost any hospital.”, Mintzberg and Glouberman 2001), being based on professionals’ activity. Professionals play a wide span of autonomy and they can resist towards changes and control systems that do not involve them, thus implicating their deep involvement in designing and implementing effective management control devices. Due to this characteristic, the decision makers about measurement systems in public health are not only the politics and top managers at different levels (national, regional and local) but also the professionals at their level. But which are the roles of these players at their organizational levels? Do they play a different role in desing and implementation of a performance measurement system? And which are the interactions among them? The aim of this paper is to answer at these questions through the experience of the design of the so-called Prodotti Finiti system for measuring output and performance of the prevention services in Tuscan health care system. The necessity of this performance measurement system rises from a lack that regards the primary care and the collective prevention services: while in the hospital services the DRGs system has been developed and used as a shared tool to measure output and performance, in the primary care and the collective prevention services there is no shared and uniform way to measure the services provided. The idea of using the Prodotti Finiti (Final Products) as objects of performance measurement of prevention services was born at a local level in 1998; then, in 2006, it was spread to all LHAs by the regional level in order to have a uniform and shared system. The players involved in this initiative have been the local and regional levels as the promoter of the introduction of the Prodotti Finiti system and the groups of professionals as the decision-makers of what products and what elements should have to be measured. In the experience of the design of this system the professionals seem to have been the strongest decisional level: they have decided what were the objects to be measured. The political levels (regionals and local) could choose to limit the analysis to some products (as key performance areas) or to some particular elements of the products but these were second hand choices because strictly linked to the assumptions and the decisions already made by professionals. Although the choice of involving professionals in the design of the measurement system is fundamental for the consensus, it could lead to a limited power of the other decision makers, so confirming the strenght of professionals’ power in designing performance measurement systems in health care organizations.performance measurement, public health, multiple players

How to re-allocate resources within services through data benchmarking: some evidence from the Tuscan Health System.

Background Tuscany Region has implemented a multidimensional system to assess the performance of all Local Health Authorities (LHAs), based on over 130 indicators classified in 6 dimensions in benchmarking. A study was carried out to use the results of the evaluation performance system to support health system decision makers to cope with resources scarcity. Objective To quantify the amount of resources LHAs can re-allocate, taking actions in different sectors, for services with more value for patients. Methods The analysis was based on the data benchmarking of all the indicators of the performance evaluation system with an impact on the level of resources used. For each indicator, the first step was to estimate the gap between the performance of each LHA and the best performance or the regional average. The second step was to measure this gap in terms of financial value. Results The results of the analysis put on evidence that at the regional level 6 to 10 percent of the budget for healthcare (6.100 ml Euros) can be re-allocated if all the institutions achieve the regional average or the best practice. Some LHAs are already efficient but others have large room for improvement: some of them, working on efficiency and appropriatness, can re-allocate up to the 13% of their total costs in services with more value for patients. Policy Implications The implications of this study can be extremely useful for policy makers and the top management of LHAs in a public system that bases its action on cooperation more that competition. Benchmarking makes the system capable to measure the financial impact of different types of actions which can effect efficiency.Disinvestment, setting priorities, healthcare

How patients' experiences help institutions to improve care in oncological pathway.

To improve services, institutions need to listen the patients voice. The patient experience through the health care pathway can help institutions to point out the problems and to learn to design the organization putting the patient at the center of the service. Methods. Focus groups were performed on a group of patients affected by colon rectum neoplasia who had an operation during June-September 2003 in the hospitals located in three geographical districts. It was performed a focus group per district in the period between June and July 2004. Results. Overall patient were interviewed in district A, B and C, respectively. District C included a Universtiy Hospital and a Community Hospital. We choose the focus group technics because of the peculiarity of the studied disease. By a crossed reading of patients' experience we obtained two type of informations: how CORD is working (CORD is the structure which has the role of coordination of oncological pathway, according to the regional guidelines) and which are the strength ness and the weakness of the services delivered by each healthcare unit participating at the study. The patient experience in benchmarking through out different institutions, has been useful for managers to start an internal process of reviewing critical points regarding above all humanization and care coordination along the heath care pathway. Particularly interesting is the case of the University Hospital of Pisa, where the patients indications allowed the institution to reengineering the process, to improve services and empower the communication skills of the physicians and nurses involved in the clinical pathway . Conclusions. Patient point of view in oncological care was an easy tool for improving the health care pathway. It gives to health managers a simple method that allows the organization to evaluate services through the patients eyes .Focus group, Oncological pathway, Patients’ point of view