**4.1 Differences and similarities in the PMS dimensions**

A first description given by regional policy makers and regional managers on the adopted tools (reported in the table 2) outlines that often Regions adopt more than one tools in order to cover all dimensions identified by the OECD. Sometimes Regions complain to be overwhelmed by a plethora of indicators (see Piedmont and Apulia quotation).

Many Regions that developed multidimensional PMS declared to have applied the following conceptual frameworks: Basilicata and Bolzano based their PMS on balanced scorecard approach (Basilicata regional law 329/2008 and Bolzano county law 1809/2009); Trento PMS is based on EFQM (European Foundation for Quality Management) framework (Panizza, 2010); Marche PMS is based on the value chain; Lombardy based its PMS on JCHA (Joint Commission on Hospital Accreditation) while Tuscany developed its own framework with the help of the Scuola Superiore Sant'Anna of Pisa (Nuti et al, forthcoming a).


This paragraph reports the results of the three research topics analyzed regarding differences and similarities in: the PMS dimensions; the IRHSs' integration tools and in the

A first description given by regional policy makers and regional managers on the adopted tools (reported in the table 2) outlines that often Regions adopt more than one tools in order to cover all dimensions identified by the OECD. Sometimes Regions complain to be

Many Regions that developed multidimensional PMS declared to have applied the following conceptual frameworks: Basilicata and Bolzano based their PMS on balanced scorecard approach (Basilicata regional law 329/2008 and Bolzano county law 1809/2009); Trento PMS is based on EFQM (European Foundation for Quality Management) framework (Panizza, 2010); Marche PMS is based on the value chain; Lombardy based its PMS on JCHA (Joint Commission on Hospital Accreditation) while Tuscany developed its own framework

Region uses more than one tools. They are then systematized in an annual

There are both common and specific targets across Health Authorities.

Measurements are carried out by the Regional Agency for healthcare. Most of indicators are based on hospital data. *The 90% of primary care services measures is an indirect indicator of primary care performance because it comes out from hospital information systems such as the hospitalization rate for the* 

There are more tools that monitor the dimensions declared.

Mainly the recovery plan's dimensions are monitored.

LOMBARDY The theoretical framework declared by interviewee is the JCHA: Joint

MARCHE Supply chain model is the theoretical framework declared by interviewee.

*Our capacity to produce reports is higher than our capacity to read it.* 

BSC is the theoretical framework declared by interviewees.

There is an observatory on equity and epidemiologic aspects that supports

As regards as the customer and citizens satisfaction, it was carried out by the

*Primary care measures are weak, we are not able to gather reliable information. So our* 

There is a plethora of tools with lots of information.

regional statistician department using panel.

*systems are biased by the hospital side.* 

Commission Hospital Accreditation.

analysis for health policy.

BSC is the theoretical framework declared by the interviewees. Standards are set

*Liguria is one of the regions that have to follow a recovery plan from the financial deficit so that many actions, objectives and tools are determined by this particular situation* 

regional attitude towards the use of benchmarking. Quotation are reported in italics.

overwhelmed by a plethora of indicators (see Piedmont and Apulia quotation).

with the help of the Scuola Superiore Sant'Anna of Pisa (Nuti et al, forthcoming a).

**4.1 Differences and similarities in the PMS dimensions** 

 **Regions Information about PMS framework** 

*heart failure…*

by the regional law 329/2008.

CAMPANIA The recovery plan's dimensions are monitored

BSC.

**4. Results** 

BASILICATA

FRIULI VENEZIA

GIULIA

LIGURIA

PIEDMONT

BOLZANO


Table 2. Information about regional PMS framework

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


Table 3. OECD dimensions covered by regional PMS.

Performance Measurement

BOLZANO

TRENTO

APULIA

SARDINIA

SICILY

TUSCANY

UMBRIA

VENETO

 **Regions PMS' Dimensions** 

Features of the Italian Regional Healthcare Systems: Differences and Similarities 305

4. Customer and citizens satisfaction (periodical survey on a panel)

1.Efficiency and economic sustainability

1. Activation of some pathway projects

4. Specific indicators for each Health Authorities

4. Patient satisfaction, (periodical surveys)

The health improvement and outcome is the other dimension declared by all Regions. That is due to the fact that some indicators included in the recovery plan are those related to an appropriate use of resources such as the number of medical DRGs discharged by surgical wards. Apart these indicators there are a lot of differences concerning the type of indicators included: only few Regions declare to include quality indicators or clinical risk (safety) indicators (see table 4) in addiction other differences concern the technique applied in order to

6. Efficiency and financial performance

2. Activation of projects mainly based on developing health

 2. Appropriateness 3. Quality and outcome

1. Regional strategies 2. Financial perspective

5. Appropriateness

information services 3. Financial perspective

1. Appropriateness

1. Population health, 2. Regional policy targets,

3. Quality of care,

5. Staff satisfaction,

3. Appropriateness 4. Regional strategies

3. Clinical risk management

2. Quality (for specific areas)

2. Quality

1. Quality 2. Efficiency 3. Appropriateness

1. Efficiency

Table 4. Details of regional PMS dimensions

 2. Financial dimension 3.Clinical performance 4.Appropriateness 5.Regional strategies 6.Customer satisfaction

3. Efficiency 4. Quality

6. Equity

1. Efficiency

Efficiency is the dimension with the highest level of commonalities across Regions. It can be addressed to the fact that Regions developed PMSs first focusing on standards and targets concerning managerial efficiency and cost containment, and then they extended their attention to other issues (Ancona , 2008). The predominance of the efficiency dimension emerges when there are consistent problems on keeping financial equilibrium and the Italian central government asks Regions for a recovery plan. Table 1 summarizes the Regions with a recovery plan in the period of interviews. Thus Regions under central government pressure for reducing financial deficit are mainly focused on costs containment. As a consequence the other dimensions (ie. Responsiveness) are considered less urgent and, as a matter of facts, they are not strictly monitored (this is well highlighted by the quotation of Liguria Region reported in table 2).


Efficiency is the dimension with the highest level of commonalities across Regions. It can be addressed to the fact that Regions developed PMSs first focusing on standards and targets concerning managerial efficiency and cost containment, and then they extended their attention to other issues (Ancona , 2008). The predominance of the efficiency dimension emerges when there are consistent problems on keeping financial equilibrium and the Italian central government asks Regions for a recovery plan. Table 1 summarizes the Regions with a recovery plan in the period of interviews. Thus Regions under central government pressure for reducing financial deficit are mainly focused on costs containment. As a consequence the other dimensions (ie. Responsiveness) are considered less urgent and, as a matter of facts, they are not strictly monitored (this is well highlighted by the quotation

of Liguria Region reported in table 2).

 **Regions PMS' Dimensions** 

1. Acute care

CAMPANIA Efficiency and financial aspects

production.

2. Outcome

2. Need 3. Demand 4. Supply 5. Access

1. Efficiency 2. Equity

2. Territorial services

4. Continuty of care

7. Financial perspective 8. Human resources

3. Primary care and prevention

5. Integration between social and sanitarian care 6. Customer satisfaction (normative fulfilment)

3. Promoting the good clinician practices 4. Improvements on population's health status The customer satisfaction is carried out by civic audits.

LIGURIA There are indicators of efficiency, appropriateness and health

3. Customer satisfaction (periodical surveys)

Customer satisfaction is carried out by civic audits.

1. Financial and efficiency perspective

1. Population's characteristics;

6. Outcome/output 7. Financial perspective

2. Financial perspective 3. Ad hoc analysis (equity)

1. Efficiency

BASILICATA

FRIULI VENEZIA GIULIA

LOMBARDY

MARCHE

PIEDMONT


Table 4. Details of regional PMS dimensions

The health improvement and outcome is the other dimension declared by all Regions. That is due to the fact that some indicators included in the recovery plan are those related to an appropriate use of resources such as the number of medical DRGs discharged by surgical wards. Apart these indicators there are a lot of differences concerning the type of indicators included: only few Regions declare to include quality indicators or clinical risk (safety) indicators (see table 4) in addiction other differences concern the technique applied in order to

Performance Measurement

groups (as reported in figure 1).

(Case A).

**benchmarking** 

Features of the Italian Regional Healthcare Systems: Differences and Similarities 307

Information gathered by interviews and documental analysis highlight that Regions with comprehensive tool covering almost all OECD dimensions are those that are supported by internal (such as regional agency or epidemiologic observatory) or external (such as university centres) institutions. In this perspective it seems that innovative management tools are associated to a fertile cultural environment (ie. specialized university centre or observatory).

Responses about integration between PMS and rewarding system can be classified into three

In the first group there are Regions that have coped with central pressure on the deficit control, they suspended the CEOs rewarding system or linked it to normative fulfilments

In the second group (Case B) there are Regions (Basilicata and Sardinia) which show full integration between rewarding system and performance measurement system. These regions have recently implemented performance measurement systems and in order to enforce them, they decided to strictly link the rewarding system. To this extent the

The last group of Regions (Case C) is characterized by a partial integration of rewarding and performance measurement systems. These Regions decided to make a selection of measures

Fig. 1. Integration between performance measurement systems and rewarding system.

**4.3 Differences and similarities in the regional attitude towards the use of** 

system they use the rewarding system as a driver of change.

opportunity to improve their performance.

In general PMS covers much more topics than the rewarding system as it is represented in case A and C. These two groups collect the majority part of the Regions that participated in the study. The only case where the rewarding system is almost overlapping with the PMS adopted is the case B. It seems that when Regions seek to implement new reliable control

Benchmarking is seen by all Regions, with the exception of Apulia, as an interesting

rewarding system introduces an innovative way of measuring performance.

to be rewarded adding to the PMS' measures also other type of decisions.

**4.2 Differences and similarities in IRHS integration tools** 

calculate some indicators for instance the large (or null) use of dichotomous (yes/no) indicators or the use of specific indicators related to the treatment of particular chronic conditions.

Responsiveness and equity are the dimensions less monitored and also those that register a high number of differences.

Regarding responsiveness, common indicators are those related to waiting times. Besides this type of indicators, other monitored topics concern patient satisfaction. Nevertheless lots of Regions declare to monitor patient satisfaction, methods are quite different from each others for instance some Regions, such as Lombardy and Bolzano, run sample surveys; others use the civic audit and finally others, such as Basilicata, control that surveys have been executed by Health Authorities without having information about the results (see table 4).

Concerning Equity, the Commission on Social Determinants of Health (CSDH) of WHO asserted that the systematic and continuous measuring of equity indicators is a fundamental step in order to close the gap of inequities (CSDH, 2008).

Only some Regions declare to have monitored equity. Most indicators related to equity require surveys so that many Regions seldom measured these type of indicators. The only two Regions that are able to measure systematically equity in access for some services (ie. Hospital discharges) are Piedmont and Tuscany (see table 5).


Table 5. Regional responses on equity dimension

Information gathered by interviews and documental analysis highlight that Regions with comprehensive tool covering almost all OECD dimensions are those that are supported by internal (such as regional agency or epidemiologic observatory) or external (such as university centres) institutions. In this perspective it seems that innovative management tools are associated to a fertile cultural environment (ie. specialized university centre or observatory).
