regional–based quality management of health services: the ... · wennberg-zurich.org 12.04.18...

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Regional–based quality management of health services: the Italian approachSabina Nuti M a n a g e m e n t a n d H e a l t h L a b o r a t o r y - S a n t ’ A n n a S c h o o l o f A d v a n c e d S t u d i e s , P i s a ( I t a l y )

WENNBERG INTERNATIONAL COLLABORATIVESPRING POLICY MEETING 2018


C u r r e n t e x p e n d i t u r e o n h e a l t h , % o f g r o s s d o m e s t i c p r o d u c t

Y e a r : 2 0 1 6

Source: OECD Health Statistics 2017

17.2%

12.4%11.3% 11.0% 11.0% 10.9% 10.6% 10.5% 10.5% 10.4% 10.4% 9.7% 9.6% 9.0% 8.9% 8.9% 8.6% 8.3%

0%2%4%6%8%

10%12%14%16%18%20%


The Italian healthcare system

It’s a Beveridge-like model: U n i v e r s a l , C o m p r e h e n s i v e (almost), F r e e , Financed by g e n e r a l t a x a t i o n .

It is organized in three levels:

– The n a t i o n a l level is responsible for national health planning, including general aims and annualfinancial resources and for ensuring a uniform level of services, care and assistance (LEA).

– The r e g i o n a l level has the responsibility for planning, organizing and managing its health caresystem through LHA’s activities in order to meet the needs of their population.

– The l o c a l level (Local Health Authorities): provides care through public and/or private hospitals,primary care and prevention services.


4

S i n c e 2 0 0 8 , Re g i o n s i n v o l v e d i n t h e S a n t ’A n n a n e t w o r k s h a r i n g t h e p e r f o r m a n c e e va l u a t i o n s y s t e m ( 3 0 0 i n d i c a t o r s ) :

• Veneto• Toscana• Liguria• Umbria• PA Trento• PA Bolzano• Marche• Basilicata• Emilia Romagna• Friuli Venezia Giulia• Lombardia• Puglia

http://performance.sssup.it/network


The F ive Assessment Bands


P e r c e n t a g e o f c a e s a r e a n s e c t i o n d e l i v e r i e s( N T S V )


S t a n d a r d i z e d h o s p i t a l i z a t i o n r a t e f o r t o n s i l l e c t o m y


The PES sys tem

Friuli Venezia Giulia

Region level Local authority level


Key critical features

Tuscan Governance System

VISUAL REPORTING SYSTEM

PUBLIC DISCLOSURE OF RESULTS

STRONG POLITICAL COMMITTMENT AND CONSISTENCY OVERTIME

PERFORMANCE EVALUATION SYSTEM LINKAGE TO CEO’S REWARDING SYSTEM

Nuti S, Seghieri C, Vainieri M. Assessing the effectiveness of a performance evaluation system in the public health care sector:some novel evidence from the Tuscany Region experience. Journal of Management and Governance, 2012

PROFESSIONALS AND MANAGERS LARGE INVOLVEMENT


Performance


F e m u r f r a c t u r e s : s u r g e r i e s w i t h i n 4 8 h o u r s , T u s c a n y , 2 0 1 5


Diabetes-Related Major Amputation at lower limbs Rate per million residents – MeS-Lab Tuscany PES results, 2012. Source: MeS-Lab

But to improve qual i ty of care and create value for pat ients we need to work on the determinants…


When outcome unwarrented variat ion is determined by the

absence of integrated care…


Behind the numbers: professionals… and the care organization

Diabetes-related major amputat ion rate per mi l l ion residents in Tuscan Local Health Authori t ies (LHAs), 2009-2011

Differences could not be fully explained by the diabetes prevalence across LHAs

My cases are more complexbecause I work in the regionalreference centre

National and regionalbest performance overtime


Age- and gender-standardized Diabetes-Related Major Amputation at lower limbs per million residents in Tuscany, 2012. Details for the delivering Health Authority. Source MeS-Lab

C h a n g i n g t h e p e r s p e c t i v e … w h e r e p a t i e n t s a r e t r e a t e d

shift professionals’ attitudes towards “population medicine”. In a Beveridge healthcare system pursuing universal coverage, clinicians should not be considered responsible just for their specific departments and only for the outcomes of their patients. On the contrary, they should be involved in resources allocation decisions to foster shared responsibility <<to the population they serve, to the patients they never see, as well as to the patients who have consulted>> or that have been referred to, as “public health professionals” [Gray, 2013].


M a p p i n g a n d s h a r i n g a n e v a l u a t i o n o f t h e o r g a n i z a t i o n a l p a t h

Training of professionals and patient education Implementation of information Systems

Multidisciplinary and interprofessional team to ensure continuity of care

Screening and prevention

Access to the

outpatient clinic

Visit•Diagnostic

tests•Early

interventionFollow

up

Treatment

SurgeryRevascularization

Urgent and Emergency path

Pharmacological treatment

Diabetic patients have direct access or are sent by the GPs to the outpatient clinic.

Some organizations perform diagnostic exams directly in the outpatient, whereas in others radiologists departments have dedicated hours to exams for diabetic patients.

LHAs without cath labs send their patients to other LHAs or THs for revascularization. Dedicated hours of the cath lab to lower limbs revascularizations are not present in every organization.

Some organizations provide a dedicated “fast track” for exams, revascularization procedures and interventions. Many organizations are very flexible in timing and scheduling in order to meet urgent needs.

Communication with primary care professional is considered an aspect to be improved in almost every organization (training courses). Education to patients and caregivers is provided not only as individual education during visits, but also as group education. The level of development and implementation of Information Systems are very different among organizations

Sometimes there are problems of communication and collaboration among professionals and providers, especially in big organizations (such as THs).

The intervention is often planned and scheduled involving the diabetologists. After the intervention the diabetologists are generally informed in order to take appropriate action for follow-up treatments.


I always do my best for my patients and I thought to beon the right way. The population based perspective helped

me to have a look at the entire path of the patients. I realized that our integration with the other professionals(namely PC) has to be boosted. Moreover this analysisallowed me to have data and results that I can use to

reorganize the pathway within the hospital wall.

A s h a r e d p r o p o s a l f r o m p r o f e s s i o n a l s t o r e g i o n a l h e a l t h d e p a r t m e n t

A REGIONAL PROTOCOL FOR DIABETIC PATHWAY (focusing on integration between PC and H )

AND A SPECIFIC DOCUMENT FOR THE DIABETIC FOOT PATH


Improving resultsDiabetes-related major amputat ion rate per mi l l ion residents in Pisa

LHA, 2012-2015


Categories of care variation revised

Effective Care

Refers to services that are of proven value and have no significant

tradeoffs; the benefits of the services outweigh the risks. Hence, all patients should receive them.

Supply-sensitive care

Represents services for which the supply of physicians and other

resources—such as hospital beds—strongly influences the amount of

care delivered

Preference-sensitive care

Comprises care for conditions that have more than one treatment

option, each with its own benefits and tradeoffs. For these conditions,

patients’ preferences should take into account

Effective Integrated Care

Refers to variation due to lack of integration and

communication among professionals and services

along the whole care paths.


Let’s play the patient’s music….

the positive metaphor of the “stave”

The stave, as well as the dartboard, relies on the five colour bands (from red to dark-green).

These bands are now displayed horizontally and are framed to represent the different phases

of care pathways. This view allows users to focus on strengths and weaknesses

characterizing the healthcare service delivery in the different pathway phases.


From Siloes to Pathway

Primary care

Hospitals

Teaching Hospitals


Bevan, G., Evans, A. Nuti, S. (2018). Reputations count: why benchmarking performance is improving healthcare across the world. Health Economics, Policy and Law.

Nuti, S., Seghieri, C., & Vainieri, M. (2013). Assessing the effectiveness of a performance evaluation system inthe public health care sector: some novel evidence from the Tuscany region experience. Journal of Management& Governance, 17(1), 59-69

Nuti, S., Vola, F., Bonini, A., & Vainieri, M. (2015). Making governance work in the health care sector: evidencefrom a ‘natural experiment’in Italy. Health Economics, Policy and Law, 11(01), 17-38.

Vainieri M., Vola F., Gomez Soriano G., Nuti S. (2016), “How to set challenging goals and conduct fair evaluationin regional public health systems. Insights from Valencia and Tuscany Regions”, Health Policy

Nuti S; Seghieri C (2014) Is variation management included in regional healthcare governance systems? Someproposal from Italy. Health Policy vo.114

Nuti S. Vainieri M (2016) Strategies and tools to manage variations in regional governance systems. Handbookon health services research Vol 1 Springer

Nuti S. Vola F. Vainieri M. (2017) Priorities and targets: a methodology to support the policy-making process inhealthcare. Public money and management

Vainieri, Ferrè, Giacomelli, Nuti (2017) Explaining performance in healthcare: how and when top managementcompetencies make the difference. Health care Management Review

S e l e c t e d b i b l i o g r a p h y r e l a t e d t o t h e I t a l i a n R e g i o n a l P E S


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regional–based quality management of health services: the ... · wennberg-zurich.org 12.04.18...

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