Managing gaming phenomena in the Tuscan performance evaluation system.

Abstract

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