MACCHIA A

S. NUTI

NUTI, Sabina

MACCHIA A.

Archivio della ricerca della Scuola Superiore Sant'Anna

   1THE EMPLOYEES POINT OF VIEW IN THE PERFORMANCE MEASUREMENT SYSTEM IN TUSCANY HEALTH AUTHORITIES Published in Healthcare Systems Ergonomics and Patients Safety, edited by R. Tartaglia, S. Bagnara, T. Bellandi, S. Albolino, Taylor and Francis Editors,  London U.K., 2005, pp. 373-77  S. Nuti, A. Macchia1 1Healthcare Management Laboratory, Sant'Anna School of University Studies and Tuscany Region Government, P.zza Martiri della Libertà, 56127 Pisa, Italy Lately healthcare institutions all over the world have been working on performance evaluation in terms of return on investment, efficacy, efficiency and the quality of the services that they provide. At present in Italy, Tuscany Region is testing an integrated model for measurement where “internal assessment” is one of the area included since employees satisfaction affects institution’s global performance.  Introduction  In 2004 the project was entrusted to the Scuola Superiore Sant’Anna and four health authorities were selected to participate in the experiment: Azienda USL 3 of Pistoia, Azienda Usl 5 of Pisa, Azienda USL 8 of Arezzo and the teaching hospital of Pisa. The aim of the project was to give a general outline for the management of the Health authorities, useful both for performance evaluation and for the enhancement and promotion of the results. Tuscany Health Care System strives to stand out for the process of cooperation and non competition between the subjects dedicated to providing health care services. In this context it is important to plan and develop a transparent and shared evaluation system, capable of monitoring different strategic dimensions (Kaplan and Norton, 1993). Six areas have been identified for the final representation of performance measurement results. These were considered capable of highlighting the essential aspects of performance in a complex organization. They are: • Assessment of the population’s state of health.  • Assessment of capacity to follow regional guidelines. Tuscany’s health authorities are not    2only required to demonstrate their ability to function efficiently and effectively as autonomous bodies, but also as units making up the regional healthcare system, working as a team in order to make the most of synergies and to guarantee access and equality to all the region’s population. • Assessment of economic and financial performance. This is the verification of each health authority’s capacity to pursue the three conditions of balance in the economic and financial sphere: the income balance, the monetary balance, and the financial balance.  • Clinical and health assessment. This area includes results regarding quality, appropriacy, effectiveness, and the capacity to govern supply and demand of the health system.  • External assessment. This is the evaluation of health authority activity by citizens and users of the health service.  • Internal assessment. This area deals with the levels of health authority staff satisfaction.  The decision to include this area of investigation is based on the consideration that the “organizational climate”, the employees motivation and the level of utilization of management tools strongly affect the institution’s global performance and is often the true element that makes the difference (Schneider, 1987). Having up to date equipment and high level of clinical professionals is not sufficient to ensure high quality service to patients and citizens. You need a whole organization able to work as a team, enforcing on one side clinical performance and, on the other, efficiency, i.e. the correct use of the available resources and above all a patient centred care (Ford, Fottler, 2000). Many studies now show an important correlation between employee satisfaction levels, the organizational climate of an authority and user satisfaction with services provided. In order to improve results it is therefore necessary to focus on the management systems and mechanisms designed to support the involvement and the giving of responsibility to operators with the aim of improving services. Also assessed in this area are internal services (supplies, information system, etc.) and the ability of the health authority to use the basic management tools. In order to provide an adequate representation of the results reported by the health authorities in each of the areas identified, a “target” diagram was used, divided into five assessment bands. The more an authority is capable of reaching objectives and obtaining results in the various performance areas, the nearer the centre is the performance indicator (figure 1).   231112141516181921202224 23252617113273031353637763940 4142433828109 298FINANCIAL EVALUATIONPERFORMANCEEMPLOYEESSATISFACTIONPATIENT/CITIZENSATISFACTIONCLINICAL EVALUATION PERFORMANCECONSISTENCY vs REGIONAL STRATEGIESPOPULATION’SHEALTH STATUS   3Figure 1. Target diagram  Internal Assessment  The internal assessment was made through the use of two complementary tools: analysis of a number of “Objective Indicators” and a staff questionnaire. The questionnaire-based survey foresaw the use of two types of tool: questionnaire “A” to be answered by all top managers, and questionnaire “B” to be answered by a random stratified sample of all health authority employees (table 1) in which both the macro area (hospital, area, prevention, administration and management) and the role (medical directors, coordinators, other employees) are represented. Table 1. Survey data Health Authority N° of employees N° of sampled employees (A+B) N° of employees interviewed Interviewed/total 1 2.853 979 405 14,2 % 2 2.118 869 502 23,7 % 3 3.337 1.357 735 22 % 4 4.732 879 483 10,2 %  The questionnaires are similar in size (70 questions) and items investigated (listed below), except for the one regarding “internal service assessment” which was specifically singled out for top managers:  1. working conditions; 2. team working; 3. manager rule; 4. communication and information processes; 5. management mechanisms (budget and control systems, training,...) 6. internal services (IT, supply service, maintenance, e-mail and intranet,...) The questions are formulated differently depending on whether they are addressed to directors with “management/budget” responsibilities, or to other staff with a professional role. Employees had to answer to all the questions giving a score on a scale between 1 and 7, where 1 standed for a bad performance and 7 for a very good one. The survey was conducted with on-line questionnaires for both groups of staff, over a period of eight weeks, two for each authority. The questionnaires were given within the health authority itself and governed by the Sant’Anna School server. Then, the data gathered have been processed and aggregated depending on homogeneous investigation items, in order to feed synthetic indicators which represents the synthesis of a “tree” of indicators. For example, the assessment of working conditions, is given by manager and employees satisfaction levels with their own jobs, working conditions and team working. These three conditions in their turn refer to other aspects which were also assessed, such as working in the health authority, the job in itself, the level of responsibility given, and willingness to modify one’s own position (figure 2).   Job within the authorityJob in itselfResponsabilityWillingness to changes JobWorking environmentWorking atmosphereWorking conditionCollaboration within one’s own departmentControl by the ManagementConflicts management capacityCollaboration among departmentsTeam workingWorking condition assessment SOURCE: internal assessment survey summer 2004Managers satisfaction level about working conditions    4Figure 2. Working condition assessment indicator 11 indicators have been used to evaluate the organizational climate: the first 2 are “Objective Indicators”, while the other 9 come from the survey, in particular indicators 3-4-5 and 6 from questionnaire A and indicators 7-8-9-10 and 11 from questionnaire B (table 2).  The range of the indicators score moves from 1 to 5, where 1 is the worst and 5 the best performance. Indicators 1, 2 and 11 are generally expressed as a percentage, but we had to turn them in score  in order to put them into the “target” previously described.   Table 2. Internal assesment results (1 to 5)                       Health Authority Indicators n. 1 n. 2 n. 3 n. 4 1. Rate of absenteeism 1,9 1,9 1,9 1,9 2. Rate of accidents at work 1,1 3,2 0,9 1,5 3. Internal services assessment -  (A) 2,4 2,9 2,5 2,5 4. Budget assessment – (A) 3,3 3,4 2,5 0,9 5. Working condition assessment – (A) 3,4 3,8 3,4 3,8 6. Top management assessment – (A) 2,8 3,1 2,6 2,9 7. Training assessment – (B) 2,8 2,9 2,8 3,1 8. Trend – (B) 2,4 2,5 2,3 2,7 9. Working condition assessment – (B) 3,2 3,2 3,2 3,4 10. Management assessment – (B) 2,5 2,5 2,4 2,7 11. Rate of participation in the survey – (B) 1,9 2,8 2,7 2,5  Results   The project carried out allowed for the first time in Tuscany to consider different types of results simultaneously. Even if each helthcare authority presents points of weekness and strength, it is undeniable that there is a strong relationship among the results in the internal performance, clinical and health assessment and the external one. As shown in table 2, the health authority n.2 has achieved better results in most of the items regarding the internal assesment. This same institution has registered also a better performance on the other dimensions of the performance evaluation system. This points out how relevant is the employees satisfaction and motivation to achieve quality and good service for patients. This hyphothesis will be tested considering the results of all the sixteen health authorities at the end of 2005. References Journal Ford, R.C. and Fottler, M.D. 2000, Creating Customer-Focused Health Care Organizations, Health Care Management Review, Fall, 18-33 Kaplan, R.S.and Norton, D.P.1993, The balanced scorecard - Measures that Drive Performance; Putting the balance scorecard to work; Harvard Business Review; Sept-Oct Schneider, B. 1987, Le persone fanno il posto, Psicologia e Lavoro, 66-67, 19-39     5 

The employees point of view in the performance measurement system in tuscany health authorities

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