Impact of austerity programs: Evidence from the Italian national health service.

Austerity measures are widely adopted to cope with financial straits. Since 2007 Italy has operated a financial recovery program (Piani di Rientro, PdR) in certain regions of the country. This provides an interesting setting for an intra-national analysis of the differences between the regions under a PdR program and those which are not. In the regions under a PdR, efforts to achieve economic sustainability and fiscal balance have impacted on healthcare indicators, resulting in a reduction in healthcare resources, an increase in taxes, and a general weakening of regional healthcare systems since the introduction of the program more than a decade ago. The detrimental effects of the austerity measures have become evident. As the regions under a PdR have demonstrated a sufficient level of economic stability, the national government should start revising its austerity strategy to prevent further widening of gaps in healthcare performance between regions.

Medicine and management in European hospitals: a comparative overview.

BACKGROUND: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context. MAIN TEXT: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes. CONCLUSIONS: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures.

Making doctors manage but how? Recent developments in the Italian NHS.

BACKGROUND: Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate. METHODS: This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant "lab" to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management. RESULTS: We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector. CONCLUSIONS: This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are "forced" or willing to take formal management roles.

Lean in healthcare: A comprehensive review.

BACKGROUND: Lean seems to be the next revolution for a better, improved, value-based healhcare. In the last 15 years Lean has been increasingly adapted and adopted in healthcare. Accordingly, Lean healthcare has been developing into a major strand of research since the early 2000s. The aim of this work is to present a comprehensive overview of the main issues highlighted by research on implementation of Lean in a complex contest such as the healthcare one. METHOD: Comprehensive literature review was conducted in order to identify empirical and theoretical articles published up to September 2013. Thematic analysis was performed in order to extract and synthesis data. FINDINGS: 243 articles were selected for analysis. Lean is best understood as a means to increase productivity. Hospital is the more explored setting, with emergency and surgery as the pioneer departments. USA appears to be the leading country for number of applications. The theoretical works have been focused mainly on barriers, challenges and success factors. Sustainability, framework for measurement and critical appraisal remain underestimated themes. Evaluations of "system wide approach" are still low in number. CONCLUSION: Even though Lean results appear to be promising, findings so far do not allow to draw a final word on its positive impacts or challenges when introduced in the healthcare sector. Scholars are called to explore further the potentiality and the weaknesses of Lean, above all as for the magnitude of investments required and for the engagement of the whole organization it represents increasingly strategic choice, whilst health professionals, managers and policy makers could and should learn from research how to play a pivotal role for a more effective implementation of lean in different health contexts.

Is management essential to improving the performance and sustainability of health care systems and organizations? A systematic review and a roadmap for future studies.

Recent studies have highlighted the importance of management in the health care sector. Positive correlations have been found between clinical and economic performance. Although there is still controversy regarding what kind of management and which managers should lead health care organizations and health systems, we now have interesting evidence to analyze. Starting with a systematic review of the literature, this article presents and discusses the streams of knowledge regarding how management can influence the quality and sustainability of health systems and organizations. Through the analysis of 37 studies, we found that the performance of health care systems and organizations seems to be correlated with management practices, leadership, manager characteristics, and cultural attributes that are associated with managerial values and approaches. There is also evidence that health care organizations run by doctors perform better than others. Finally, we provide a roadmap that indicates how the relationship between the management and performance of health systems and organizations can be further and more effectively investigated.

The challenge and the future of health care turnaround plans: evidence from the Italian experience.

Over the last two decades, health policy and governance in Italy have undergone decentralisation at the regional level. The central government was expected to play a guiding role in defining minimum care standards and controlling health expenditures at the regional level in order to keep the entire Italian National Health System (INHS) on track. Although health performance trends have been consistent across regions, public health expenditures have been variable and contributed to a cumulative deficit of 38 billion Euros from 2001 to 2010. To address the deficit, the government called for a resolution introducing a partial bail-out plan and later institutionalised a process to facilitate a turnaround. The upturn started with the development of a formal regional turnaround plan that proposed strategic actions to address the structural determinants of costs. The effectiveness of this tool was widely questioned, and many critics suggested that it was focused more on methods to address short-term issues than on the long-term strategic reconfiguration that is required for regional health systems to ultimately address the structural causes of deficits.We propose an interpretative framework to understand the advantages and disadvantages of turnaround plans, and we apply the findings to the development of policy recommendations for the structure, methods, processes and contexts of the implementation of this tool.

The rise of governmentality in the Italian National Health System: physiology or pathology of a decentralized and (ongoing) federalist system?

In this paper, we aim to discuss the implications and lessons that can be learnt from the ongoing process of federalism affecting the Italian National Health System (INHS). Many countries are currently taking decisions concerning the decentralization or re-centralization of their health-care systems, with several key issues that are illustrated in the recent history of the INHS. The decentralization process of INHS has produced mixed results, as some regions took advantage of it to strengthen their systems, whereas others were not capable of developing an effective steering role. We argue that the mutual reinforcement of the decentralization and recentralization processes is not paradoxical, but is actually an effective way for the State to maintain control over the equity and efficiency of its health-care system while decentralizing at a regional level. In this perspective, we provide evidence backing up some of the assumptions made in previous works as well as new food-for thought - specifically on how governmentality and federalism should meet - to reshape the debate on decentralization in health care.

Budgeting and performance management in the Italian National Health System (INHS): assessment and constructive criticism.

PURPOSE: The aim of the paper is to trace the history and development of performance measurement and management systems in the Italian National Health System (INHS), to identify their key characteristics, and to provide a critical assessment of their implementation. DESIGN/METHODOLOGY/APPROACH: A combination of literature review, action-research and fieldwork conducted over a ten-year period in several Italian health care organizations. FINDINGS: Performance management has grown considerably in the INHS over the last 15 years. Explanations for this growth include normative, coercive and mimetic isomorphism, the introduction of quasi-markets, the adoption of DRGs, an increased focus on clinical governance and innovative practices in human resource management. RESEARCH LIMITATIONS/IMPLICATIONS: The paper shows how performance management has been implemented in the INHS and why it can still be considered a "work in progress". PRACTICAL IMPLICATIONS: The introduction of performance management systems has stimulated greater accountability and promoted a more cost conscious culture in healthcare organizations. Nevertheless, there are many problems that remain to be solved if performance management arrangements are to deliver the desired improvements in performance. ORIGINALITY/VALUE: The paper advocates the need for reduced isolationism and increased international comparison with concomitant evaluative effort.

The rise and fall(acy) of clinical directorates in Italy.

Clinical Directorates (CDs), in the sense of "intermediate organizational arrangements through which defined parts of larger hospitals health services are managed", were introduced in the Italian National Health Service (INHS) by law after the major reform of 1992. By means of such reform, accountability chains within INHS hospitals were streamlined. Changes looked at strengthening the role of management in hospitals as a strategy to improve efficiency in the provision of services. From this stream of managerialism emerged the attempts to re-organize hospital activities along the lines of clinical directorates. The aim of this paper is to outline the context in which CDs initially developed in Italy as the "one best way" to address current hospital problems and the reasons why they are now challenged due to not coming up to expectations. To do so we run through the last 10 years of history of CDs in Italy and propose an interpretative framework to understand the grounds for their partial failure and success.

Strategies for multi-hospital networks: a framework.

The last two decades have seen the significant emergence of multi-hospital networks (MHNs) in the health sectors of all industrialized countries. Such networks seem to represent an organizational choice, which provides interesting opportunities to cope with cost and quality issues stressing the health field. This work proposes and discusses a framework for strategies that can be implemented by MHNs to achieve projected benefits. The estimated advantages are then weighed against unexpected or underrated drawbacks and empirical evidence. The conclusions point out MHNs as viable future alternatives for freestanding hospitals looking to improve their efficiency and financial stability, on condition that a 'proper management' of their consolidation processes is carried out. This requires extensive pre-deal analysis to critically assess what benefits could be achieved through the network's formation, as well as post-deal perseverance in implementing consolidation strategies to their full. In this perspective, specific advices apt to minimize the risk of creating MHNs in the wake of a management fashion instead of through sound rational assessments are also discussed.