Mintzberg (2012) highlights the difficulties in measuring performance in health care organizations because of the nature of their role in saving public health. “The problem with measurement is that, while the treatments exist in standard categories … their outcomes are often not standard, and therefore can be tricky to pin down by measurement. That is because we as individual patients are not standardized, and so our treatments have to be tailored to our individual needs and conditions” (Mintzberg, 2012, p. 5). The myth does not convict in absolute the measurement, but only the maniac use in health care organizations. The aim of this contribute is twofold. Firstly (this section), taking into account the criticism of Mintzberg about the measurement in health care, through the analysis of the main literature, this contribute would discuss about the relevance and the usefulness of a measurement system in a health care organization. Secondly (next section), taking into account the need for a measurement system this contribute would discuss about what should be measured and what should be not in order to reduce the criticism highlighted by Mintzberg in its Myths. Healthcare organizations are among the most complex in society, and they provide services to the general public and take care that these services are provided in the best manner, in an efficient and effective way in the respect of financial sustainability. Moreover, health care expenditure represents a major use of a nation’s financial resources and has been growing rapidly over the time. Factors such as the ageing population, the increased personal use of health care, and medical advances that have opened the way for more treatment options and diagnostics have contributed to a rise in the demand for health care. Increased pressures on health care resources have led policy makers, administrators, and physicians to search for more efficient ways to deliver health services (Peacock et al., 2001). Efficiency improvements in the health sector, even in small amounts, can yield considerable savings of resources or expansion of services for the community. Managing with patients is a collective and cooperative effort that requires continuous communication of performance data and is subject to emerging contingencies that require specific activities. Since patient responses to care can never be fully anticipated, treatment is never really routine. Healthcare system is further characterized by distributed decision making by people with different perspectives. In performing these purposes, health care organization manage with several human, technical and financial resources (Stahr et al., 2000), which are used in a series of processes aiming to improve the medical condition of the patient and contribute to healthier communities (Rivers and Boe, 1999). Value for the patient is created by health care providers’ combined efforts over the full cycle of care, and the benefits of any intervention for ultimate outcomes is related to the effectiveness of other interventions throughout the care cycle (Porter, 2010). Finally, the National Health System of some countries (e.g. Italy, UK) is mostly tax-funded and financial resources attributed to health care organizations are related to their performances and results (Jommi et al., 2001). To deal with the complexity of health care organizations, New Public Management (NPM) policies have been introduced into public healthcare across most OECD countries from the 1980s (Malmmose, 2012). Theory (e.g. Andrews, 2013; Alonso et al., 2015) suggests that policies based on NPM may enhance the efficiency of public service delivery, such as health care provision. According to the NPM philosophy, performance measurement becomes a central concept for audit and overseeing bodies (Lapsley, 2008; Mkasiwa and Gasper, 2013) in doing their job. About the usefulness of a measurement system in a health care organization, in the literature, two point of view compete with each other. The first one criticizes the measurement system because it deviates physicians from their mission. In more specific terms, some literature criticizes performance measurement in health care organizations because the maniac use of the measurement systems may stress physicians. In fact, in adopting NPM philosophy, physicians change in administrator (Jones, 1999), and their job and results (performances) were stressed by the limited financial resources available for the health care system. Several researches have shown that physicians would like and need more stability, less administration and close contacts to patient and colleagues (Brorström et al, 2008) which are in conflict with implementing new organization models and performance measurements (e.g. Mannion et al, 2007). Moreover, chief executives and directors in the health care in the UK are not motivated by financial rewards and personal reputation, but by more responsive service to patients, opportunity to increase staff moral and increased quality of results (Mannion et al., 2007). This approach is not consistent with the NPM that focuses on financial sustainability and effectiveness of health care organizations. Literature (Vakkuri and Meklin, 2006) highlights that methodologies, techniques, standards and indicators (cf. Brown et al., 1993) were implemented in health care organizations by transposing them from private organizations, without considering the nature of these non-profit organizations. Probably, these methodologies are less suitable for health care organizations (Lapsley and Mitchell, 1996) because of their organizational learning capacities, the specificity of their output, and/or the incomplete data systems (Vakkuri, 2003). The literature (Propper and Wilson, 2003) highlights that the risk of a measurement system is the misinterpretation and the misrepresentation of performances. In U.S. health care system, performance measures and measurement have caused inappropriate care and have decreased the focus of hospitals on patient concerns and services (Powell et al., 2012). In the UK, performance measurement has caused long waiting lists (Propper and Wilson, 2003). Moreover, performance measures have caused manipulation of evidence (Gasper and Mkasiwa, 2013). Health care performance measurement systems are focused on costs of care and limit the degree of freedom a physician has as a way to cut costs. In particular, Porter (ICHOM, 2015, p. 32) highlights that physicians have to pay great attention to costs, to comply with hospital’s budget. Spigelman (2006, p. 3) discussing about the measurement of court performances (public sector), points out that not everything that counts can be counted and measured. Some matters can only be judged, in the sense that they can only be assessed in a qualitative way. The second point view, instead, supports the measurement systems in health care organizations because it helps management to control for efficiency, effectiveness and for financial sustainability of these organizations. Health-care providers share a common goal: providing high quality care to their patients. Measuring performance can help in understanding how well health care organization is accomplishing this goal. A measurement system allows management for an analysis of where and what changes need to be made in order to improve performance and the quality of care provided (the focus is the patient, taking into account the financing system). Moreover, measuring performance also allows providers to understand what is working well, and the information can be shared with other providers who can learn from these successes. According to this point of view, explicit formal measures of performance are promoted all over the world as an important tool to improve organizational efficiency and effectiveness (Hood, 1995, Halachmi, 2012), because they incentive productivity, contribute to the legitimacy of the organization, stimulate learning processes, and generate information that may enhance an organization’s intelligence (de Bruijn and Van Helden, 2007). In other words, a major part of NPM’ purpose is to implement management accounting and managerial performance measurements systems in these organizations in order to control for costs, becoming market-oriented to meet patients’ needs. At the same time, these systems make the health care organizations accountable for their measured performance and increasingly basing resource allocation on performance. Thus, one of the core issues of NPM is the health system performance (and outcomes) measurement (Dunleavy et al. 2006) in order to increase value for patients and the public in general. Information (the output of a measurement system) plays a central role in the ability of a health system to secure improved health for its population. It can be used in many diverse ways, such as tracking public health, monitoring health care safety, determining appropriate treatment paths for patients, promoting professional improvement, ensuring managerial control and promoting the accountability of the health system to the public. Underlying all of these efforts the performance measurement drive the decisions of different stakeholders (e.g. patients, clinicians, managers, governments and the public) (Smith et al., 2008). The fundamental role of performance measurement system is to help stakeholders to make informed decisions (Smith et al., 2008, p. 1). Based on that stated above, and taking into account the organizational complexity, the particular output (outcome), the financial sustainability of health care organizations, a performance measurement system should be needed in in order to monitor their efficiency, effectiveness, and financial sustainability. Probably, these health care organizations need for specific measurement systems taking into account the nature of the outcome and the specificity of the health services. Measurement is an important part of any effort to improve quality of health care system, because measurement helps in understanding the change in organization and in management in order to improve the patient experience. Hibbard et al. (2005) state that most proponents of the public release of health care performance information believe that making this information public will increase health care providers’ motivation to improve. moreover, the identification of reliable and scientifically valid performance measurement strategies would be a benefit to the policy makers and stakeholders (Hollingsworth and Street, 2006). Inefficiency measures could be also incorporated into schemes designed to improve the performance of the health care system (Peacock et al., 2001). Performance measurement also offers policy-makers a major opportunity to secure health system improvement and accountability, enabling national priorities for health reform to be translated into organisational and individual objectives (Smith et al., 2008). Therefore, its role is to improve the quality of decisions made by all actors within the health system, including patients, practitioners, managers, governments at all levels, insurers and other payers, politicians, and citizens as financial supporters. According to this point of view, measurement of performance is vital for health care organizations also for the characteristic of the financing system. To conclude, performance measurement should measure performance and outcomes, enabling innovations in care and generating value for patients and society. Nevertheless, a measurement system should not exceed some limits as regards what is measured (scope of measurement) and how it is measured (level of measurement), because if the measurement is excessively stressed it can produce much more damage than benefit. According to this point of view, next section highlights what should be measured and what shouldn’t.
Performance Measurement in Health Care: What Should and What Shouldn’t Be Measured
IULIANO, Giuseppe;MATONTI, GAETANO
;TARTAGLIA POLCINI, Paolo;
2018-01-01
Abstract
Mintzberg (2012) highlights the difficulties in measuring performance in health care organizations because of the nature of their role in saving public health. “The problem with measurement is that, while the treatments exist in standard categories … their outcomes are often not standard, and therefore can be tricky to pin down by measurement. That is because we as individual patients are not standardized, and so our treatments have to be tailored to our individual needs and conditions” (Mintzberg, 2012, p. 5). The myth does not convict in absolute the measurement, but only the maniac use in health care organizations. The aim of this contribute is twofold. Firstly (this section), taking into account the criticism of Mintzberg about the measurement in health care, through the analysis of the main literature, this contribute would discuss about the relevance and the usefulness of a measurement system in a health care organization. Secondly (next section), taking into account the need for a measurement system this contribute would discuss about what should be measured and what should be not in order to reduce the criticism highlighted by Mintzberg in its Myths. Healthcare organizations are among the most complex in society, and they provide services to the general public and take care that these services are provided in the best manner, in an efficient and effective way in the respect of financial sustainability. Moreover, health care expenditure represents a major use of a nation’s financial resources and has been growing rapidly over the time. Factors such as the ageing population, the increased personal use of health care, and medical advances that have opened the way for more treatment options and diagnostics have contributed to a rise in the demand for health care. Increased pressures on health care resources have led policy makers, administrators, and physicians to search for more efficient ways to deliver health services (Peacock et al., 2001). Efficiency improvements in the health sector, even in small amounts, can yield considerable savings of resources or expansion of services for the community. Managing with patients is a collective and cooperative effort that requires continuous communication of performance data and is subject to emerging contingencies that require specific activities. Since patient responses to care can never be fully anticipated, treatment is never really routine. Healthcare system is further characterized by distributed decision making by people with different perspectives. In performing these purposes, health care organization manage with several human, technical and financial resources (Stahr et al., 2000), which are used in a series of processes aiming to improve the medical condition of the patient and contribute to healthier communities (Rivers and Boe, 1999). Value for the patient is created by health care providers’ combined efforts over the full cycle of care, and the benefits of any intervention for ultimate outcomes is related to the effectiveness of other interventions throughout the care cycle (Porter, 2010). Finally, the National Health System of some countries (e.g. Italy, UK) is mostly tax-funded and financial resources attributed to health care organizations are related to their performances and results (Jommi et al., 2001). To deal with the complexity of health care organizations, New Public Management (NPM) policies have been introduced into public healthcare across most OECD countries from the 1980s (Malmmose, 2012). Theory (e.g. Andrews, 2013; Alonso et al., 2015) suggests that policies based on NPM may enhance the efficiency of public service delivery, such as health care provision. According to the NPM philosophy, performance measurement becomes a central concept for audit and overseeing bodies (Lapsley, 2008; Mkasiwa and Gasper, 2013) in doing their job. About the usefulness of a measurement system in a health care organization, in the literature, two point of view compete with each other. The first one criticizes the measurement system because it deviates physicians from their mission. In more specific terms, some literature criticizes performance measurement in health care organizations because the maniac use of the measurement systems may stress physicians. In fact, in adopting NPM philosophy, physicians change in administrator (Jones, 1999), and their job and results (performances) were stressed by the limited financial resources available for the health care system. Several researches have shown that physicians would like and need more stability, less administration and close contacts to patient and colleagues (Brorström et al, 2008) which are in conflict with implementing new organization models and performance measurements (e.g. Mannion et al, 2007). Moreover, chief executives and directors in the health care in the UK are not motivated by financial rewards and personal reputation, but by more responsive service to patients, opportunity to increase staff moral and increased quality of results (Mannion et al., 2007). This approach is not consistent with the NPM that focuses on financial sustainability and effectiveness of health care organizations. Literature (Vakkuri and Meklin, 2006) highlights that methodologies, techniques, standards and indicators (cf. Brown et al., 1993) were implemented in health care organizations by transposing them from private organizations, without considering the nature of these non-profit organizations. Probably, these methodologies are less suitable for health care organizations (Lapsley and Mitchell, 1996) because of their organizational learning capacities, the specificity of their output, and/or the incomplete data systems (Vakkuri, 2003). The literature (Propper and Wilson, 2003) highlights that the risk of a measurement system is the misinterpretation and the misrepresentation of performances. In U.S. health care system, performance measures and measurement have caused inappropriate care and have decreased the focus of hospitals on patient concerns and services (Powell et al., 2012). In the UK, performance measurement has caused long waiting lists (Propper and Wilson, 2003). Moreover, performance measures have caused manipulation of evidence (Gasper and Mkasiwa, 2013). Health care performance measurement systems are focused on costs of care and limit the degree of freedom a physician has as a way to cut costs. In particular, Porter (ICHOM, 2015, p. 32) highlights that physicians have to pay great attention to costs, to comply with hospital’s budget. Spigelman (2006, p. 3) discussing about the measurement of court performances (public sector), points out that not everything that counts can be counted and measured. Some matters can only be judged, in the sense that they can only be assessed in a qualitative way. The second point view, instead, supports the measurement systems in health care organizations because it helps management to control for efficiency, effectiveness and for financial sustainability of these organizations. Health-care providers share a common goal: providing high quality care to their patients. Measuring performance can help in understanding how well health care organization is accomplishing this goal. A measurement system allows management for an analysis of where and what changes need to be made in order to improve performance and the quality of care provided (the focus is the patient, taking into account the financing system). Moreover, measuring performance also allows providers to understand what is working well, and the information can be shared with other providers who can learn from these successes. According to this point of view, explicit formal measures of performance are promoted all over the world as an important tool to improve organizational efficiency and effectiveness (Hood, 1995, Halachmi, 2012), because they incentive productivity, contribute to the legitimacy of the organization, stimulate learning processes, and generate information that may enhance an organization’s intelligence (de Bruijn and Van Helden, 2007). In other words, a major part of NPM’ purpose is to implement management accounting and managerial performance measurements systems in these organizations in order to control for costs, becoming market-oriented to meet patients’ needs. At the same time, these systems make the health care organizations accountable for their measured performance and increasingly basing resource allocation on performance. Thus, one of the core issues of NPM is the health system performance (and outcomes) measurement (Dunleavy et al. 2006) in order to increase value for patients and the public in general. Information (the output of a measurement system) plays a central role in the ability of a health system to secure improved health for its population. It can be used in many diverse ways, such as tracking public health, monitoring health care safety, determining appropriate treatment paths for patients, promoting professional improvement, ensuring managerial control and promoting the accountability of the health system to the public. Underlying all of these efforts the performance measurement drive the decisions of different stakeholders (e.g. patients, clinicians, managers, governments and the public) (Smith et al., 2008). The fundamental role of performance measurement system is to help stakeholders to make informed decisions (Smith et al., 2008, p. 1). Based on that stated above, and taking into account the organizational complexity, the particular output (outcome), the financial sustainability of health care organizations, a performance measurement system should be needed in in order to monitor their efficiency, effectiveness, and financial sustainability. Probably, these health care organizations need for specific measurement systems taking into account the nature of the outcome and the specificity of the health services. Measurement is an important part of any effort to improve quality of health care system, because measurement helps in understanding the change in organization and in management in order to improve the patient experience. Hibbard et al. (2005) state that most proponents of the public release of health care performance information believe that making this information public will increase health care providers’ motivation to improve. moreover, the identification of reliable and scientifically valid performance measurement strategies would be a benefit to the policy makers and stakeholders (Hollingsworth and Street, 2006). Inefficiency measures could be also incorporated into schemes designed to improve the performance of the health care system (Peacock et al., 2001). Performance measurement also offers policy-makers a major opportunity to secure health system improvement and accountability, enabling national priorities for health reform to be translated into organisational and individual objectives (Smith et al., 2008). Therefore, its role is to improve the quality of decisions made by all actors within the health system, including patients, practitioners, managers, governments at all levels, insurers and other payers, politicians, and citizens as financial supporters. According to this point of view, measurement of performance is vital for health care organizations also for the characteristic of the financing system. To conclude, performance measurement should measure performance and outcomes, enabling innovations in care and generating value for patients and society. Nevertheless, a measurement system should not exceed some limits as regards what is measured (scope of measurement) and how it is measured (level of measurement), because if the measurement is excessively stressed it can produce much more damage than benefit. According to this point of view, next section highlights what should be measured and what shouldn’t.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
