**3. Research methods**

The study, reported in this chapter, is based on semi-structured interviews carried out in the Italian Regional Health Systems (IRHSs); Regional documents (Regional law or Regional publications) and secondary data (i.e. Italian studies and reports).

Concerning interviews, all Regional health councillors and Regional heads of health departments were invited to participate in the study.

The collection of field data mainly took place between 2008 and 2009.

The interviews focused mainly on three topics:


Nevertheless there was a questionnaire, interviews were conducted following an open approach so that interviewees could highlight their meanings and perception about the PMS and the field situation (Patton, 1990). Due to the open approach Regional interviewees were not forced to answer to all the items included in the questionnaire; as a consequence some items remained uncovered.

Both WHO and OECD based their frameworks on three main goals of health systems: (a) health improvement and outcomes; (b) responsiveness and access; and (c) assuring fairness

These organizations declined these goals into four dimensions of performance: (a) health

Using these four dimensions, Hurst & Jee Hughes (2001) compared PMS adopted by a group of countries. The study highlights that countries do not covered all dimensions

On the basis of this evidence a first aim of this paper is to map the differences and similarities of IRHSs regarding the dimensions of performance monitored by Regional top

Another burning topic related to PMS in healthcare is the use of pay for performance

It is recognized that management tools should be managed in a coordinated way, especially the linkages between rewarding system (one of the two perspective of the pay for performance) and budgeting (Flamholtz et al., 1985; Ouchi, 1979). The connection between them is a crucial factor that can determine the effectiveness of PMS at the organizational level. To this extent it appears worthy to analyze the differences in the connection between

Finally another important topic related to PMS is benchmarking. Arah et al (2003) pointed out that a group of countries, that adopted a national PMS in health care, uses benchmarking as a mechanism to drive change in terms of improvement. In this perspective benchmarking is applied in order to gather information which can help the organization to

Although benchmarking gained growing relevance in health PMS at several levels, from international to organizational level (Johnston, 2004; NHS executive, 1999; Pink et al,2001; Nuti et al. 2009), in the Italian health sector it was not widespread yet at national or regional

In such circumstances a last issue that the empirical study aims to analyze regards differences and similarities in the attitude of Italian Regional Health System (IHRS) towards

The study, reported in this chapter, is based on semi-structured interviews carried out in the Italian Regional Health Systems (IRHSs); Regional documents (Regional law or Regional

Concerning interviews, all Regional health councillors and Regional heads of health

Nevertheless there was a questionnaire, interviews were conducted following an open approach so that interviewees could highlight their meanings and perception about the PMS and the field situation (Patton, 1990). Due to the open approach Regional interviewees were not forced to answer to all the items included in the questionnaire; as a consequence some

the description of tools used for measuring the performance of health services;

publications) and secondary data (i.e. Italian studies and reports).

The collection of field data mainly took place between 2008 and 2009.

departments were invited to participate in the study.

the linkage between PMS and rewarding system;

The interviews focused mainly on three topics:

regional attitude towards benchmarking.

mechanism as a governance tool (Van Herck et al 2010, Mannion & Davies 2008).

improvement/outcomes (b) responsiveness (c) equity, (d) efficiency.

moreover often common dimensions are drill down differently.

of financial contribution. (Arah et al 2003).

managers and/or policy makers.

PMSs and the rewarding system.

level (Banchieri, 2005).

the use of benchmarking.

**3. Research methods** 

items remained uncovered.

improve its performance (Watson, 1993).

A total of 15 Regions (over 21) participated in the study. Some Regions did not participate in the study because of institutional reasons such as the election or judgmental inquiries. Taking into account these issues the answer rate was high and the responses were quite balanced across Italian Regions (see table 1).


Sources: Minister of Health, 2010 data and National Institute for Statistics.

Table 1. A snapshot of the main statistics and comments of the IHRSs

Conducted interviews generally lasted between 1 and 2 hours. They were recorded and sent to the interviewees for their validation. In addiction preliminary results of the cross-regional analysis were presented to those who participated in the study in a feedback seminar held in 2009. The discussions evolved on this occasion represented an effective means of the crossvalidation of the preliminary interpretations on the IHRSs responses on the characteristics of PMSs which were collected in a research report (Nuti & Vainieri, 2009) .

Findings coming from interviews are also supported and integrated by the documental analysis and the secondary data collected during the research.

Performance Measurement

TUSCANY

VENETO

Regions

Friuli Venezia

 **Regions Information about PMS framework** 

the only tool adopted.

APULIA Many tools are adopted in order to monitor performance.

SARDINIA Indicators are derived by the Regional Health Plan.

*general lack of control systems.*

performance of health authorities.

There is more than one tool.

Table 2. Information about regional PMS framework

Table 3. OECD dimensions covered by regional PMS.

(a) health improvement /outcomes

outcome. There is more than one tool.

measurement and the process of evaluation.

(b) responsiveness

Basilicata X X X Campania X X

Giulia X X X? X Liguria X X Lombardy X X X Marche X X X Piedmont X X X Bolzano X X X Trento X X X? X Apulia X X X Sardinia X X? X Sicily X X Tuscany X X X X Umbria X X? X Veneto X X X? X

Features of the Italian Regional Healthcare Systems: Differences and Similarities 303

TRENTO EFQM model is the theoretical framework declared by interviewees but is not

*There are too much indicators that are not systematized yet*.

SICILY Many control systems have been introduced with the recovery plan. *There is a* 

UMBRIA The epidemiological observatory makes periodical studies on equity and

The dimensions covered by all principal tools quoted by Regions are reported in table 3.

Theoretical framework on Performance Evaluation System (PES) had been developed in 2004 in collaboration with the Mes lab, study centre of Scuola Superiore Sant'Anna of Pisa that is still in charge of the measurements and surveys. PES provides Region with a striking visual picture of the overall

Regional Agency for healthcare helps Regional health department in the

(c) equity (of health outcomes, access and finance respectively);

(d) effciency (both macroeconomic

microeconomic).

and

A top down approach was used in this stage.
