The policy and politics of healthcare corporatisation: The case of the English NHS.

RATIONALE: Few accounts of healthcare corporatisation examine the effects of the 2008 financial crisis. New Politics of the Welfare State (NPWS) theories recognise the relevance of crises but give more attention to programmatic than systemic (structural) retrenchment, and little to healthcare corporatisation. OBJECTIVE: To examine what changes the 2008 financial crisis produced in the pattern of healthcare corporatisation, and the implications for NPWS theories. METHODS: Using administrative data from the English NHS during 1995-2019 we formulated a multi-dimensional index of corporatisation, tested its validity, and used it to analyse longitudinally how the financial crisis affected the balance between the responsibilization of management and re-commodification (introduction of market-like practices) in provider corporatisation. RESULTS: The financial crisis influenced NHS corporatisation through the fiscal austerity with which governments responded. The re-commodification of NHS providers stalled but not the responsibilization of NHS managers. CONCLUSIONS: The corporatisation of NHS providers faltered after the financial crisis. These findings corroborate parts of NPWS theory but also reveal scope for further elaborating its accounts of systemic retrenchment in health systems.

Organizational resilience in healthcare: a review and descriptive narrative synthesis of approaches to resilience measurement and assessment in empirical studies.

BACKGROUND: The coronavirus pandemic has had a profound impact on organization and delivery of care. The challenges faced by healthcare organizations in dealing with the pandemic have intensified interest in the concept of resilience. While effort has gone into conceptualising resilience, there has been relatively little work on how to evaluate organizational resilience. This paper reports on an extensive review of approaches to resilience measurement and assessment in empirical healthcare studies, and examines their usefulness for researchers, policymakers and healthcare managers. METHODS: Various databases (MEDLINE, EMBASE, PsycINFO, CINAHL (EBSCO host), Cochrane CENTRAL (Wiley), CDSR, Science Citation Index, and Social Science Citation Index) were searched from January 2000 to September 2021. We included quantitative, qualitative and modelling studies that focused on measuring or qualitatively assessing organizational resilience in a healthcare context. All studies were screened based on titles, abstracts and full text. For each approach, information on the format of measurement or assessment, method of data collection and analysis, and other relevant information were extracted. We classified the approaches to organizational resilience into five thematic areas of contrast: (1) type of shock; (2) stage of resilience; (3) included characteristics or indicators; (4) nature of output; and (5) purpose. The approaches were summarised narratively within these thematic areas. RESULTS: Thirty-five studies met the inclusion criteria. We identified a lack of consensus on how to evaluate organizational resilience in healthcare, what should be measured or assessed and when, and using what resilience characteristic and indicators. The measurement and assessment approaches varied in scope, format, content and purpose. Approaches varied in terms of whether they were prospective (resilience pre-shock) or retrospective (during or post-shock), and the extent to which they addressed a pre-defined and shock-specific set of characteristics and indicators. CONCLUSION: A range of approaches with differing characteristics and indicators has been developed to evaluate organizational resilience in healthcare, and may be of value to researchers, policymakers and healthcare managers. The choice of an approach to use in practice should be determined by the type of shock, the purpose of the evaluation, the intended use of results, and the availability of data and resources.

Resource dependency and strategy in healthcare organizations during a time of scarce resources: evidence from the metropolitan area of cologne.

PURPOSE: Healthcare systems are under pressure to improve their performance, while at the same time facing severe resource constraints, particularly workforce shortages. By applying resource-dependency-theory (RDT), we explore how healthcare organizations in different settings perceive pressure arising from uncertain access to resources and examine organizational strategies they deploy to secure resources. DESIGN/METHODOLOGY/APPROACH: A cross-sectional survey of key decision-makers in different healthcare settings in the metropolitan area of Cologne, Germany, on perceptions of pressure arising from the environment and respective strategies was conducted. For comparisons between settings radar charts, Kruskal-Wallis test and Fisher-Yates test were applied. Additionally, correlation analyses were conducted. FINDINGS: A sample of n = 237(13%) key informants participated and reported high pressure caused by bureaucracy, time constraints and recruiting qualified staff. Hospitals, inpatient and outpatient nursing care organizations felt most pressurized. As suggested by RDT, organizations in highly pressurized settings deployed the most vociferous strategies to secure resources, particularly in relation to personnel development. ORIGINALITY/VALUE: This study is one of the few studies that focuses on the environment's impact on healthcare organizations across a variety of settings. RDT is a helpful theoretical foundation for understanding the environment's impact on organizational strategies. The substantial variations found between healthcare settings indicate that those settings potentially require specific strategies when seeking to address scarce resources and high demands. The results draw attention to the high level of pressure on healthcare organizations which presumably is passed down to managers, healthcare professionals, patients and relatives.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service.

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

BACKGROUND: In 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions. AIMS: To determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services. METHODS: Using data from 20 acute hospital Trusts in England, we performed randomly selected structured case record reviews of patients admitted to hospital as emergencies at weekends and on weekdays between financial years 2012-2013 and 2016-2017. Senior doctor ('specialist') involvement was determined from annual point prevalence surveys. The primary outcome was the rate of clinical errors. Secondary outcomes included error-related adverse event rates, global quality of care and four indicators of good practice. RESULTS: Seventy-nine clinical reviewers reviewed 4000 admissions, 800 in duplicate. Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, particularly errors most likely influenced by doctors (clinical assessment, diagnosis, treatment, prescribing and communication): error rate OR 0.78; 95% CI 0.70 to 0.87; adverse event OR 0.48, 95% CI 0.33 to 0.69; care quality OR 0.78, 95% CI 0.70 to 0.87; all adjusted for age, sex and ethnicity. Postadmission in-hospital care processes improved between epochs and were better for weekend admissions (vital signs with National Early Warning Score and timely specialist review). Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation). CONCLUSIONS AND IMPLICATIONS: Hospital care quality of emergency medical admissions is not worse at weekends and has improved during implementation of the 7-day services policy. Causal pathways for the weekend effect may extend into the prehospital setting.

Populism and health policy: three international case studies of right-wing populist policy frames.

Over the past decade, some of the world's most stable parliamentary democracies have witnessed a revival in right-wing populist political parties, movements and leaders. Although there is a growing body of theoretical and empirical literature documenting the rise of populism, there has been very little exploration of the implications for health policy of this important political development. In this article, we draw from three illustrative international cases, originating from the USA, the UK and Italy, to explore the ways in which right-wing populism influences health policy: the election of President Trump in the United States (and subsequent healthcare reforms), the United Kingdom's vote to withdraw from the European Union (Brexit), and how this has played out in the context of the UK National Health Service, and the rise of a politically aligned anti-vaccination movement in Italy. Drawing on the work of the influential socio-political theorist Ernesto Laclau, we interpret populism as a performative political act, predicated on drawing logics of equivalence (and difference) between different actors. We use this theoretical framing to explore the ways in which the recent upsurge in right-wing populism creates a specific set of barriers and challenges for access to healthcare and the health of populations.

Managerial workarounds in three European DRG systems.

PURPOSE: Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy. DESIGN/METHODOLOGY/APPROACH: We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings. FINDINGS: Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume. RESEARCH LIMITATIONS/IMPLICATIONS: Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further. PRACTICAL IMPLICATIONS: In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'. SOCIAL IMPLICATIONS: Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection. ORIGINALITY/VALUE: So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Assessment of publication bias and outcome reporting bias in systematic reviews of health services and delivery research: A meta-epidemiological study.

Strategies to identify and mitigate publication bias and outcome reporting bias are frequently adopted in systematic reviews of clinical interventions but it is not clear how often these are applied in systematic reviews relating to quantitative health services and delivery research (HSDR). We examined whether these biases are mentioned and/or otherwise assessed in HSDR systematic reviews, and evaluated associating factors to inform future practice. We randomly selected 200 quantitative HSDR systematic reviews published in the English language from 2007-2017 from the Health Systems Evidence database (www.healthsystemsevidence.org). We extracted data on factors that may influence whether or not authors mention and/or assess publication bias or outcome reporting bias. We found that 43% (n = 85) of the reviews mentioned publication bias and 10% (n = 19) formally assessed it. Outcome reporting bias was mentioned and assessed in 17% (n = 34) of all the systematic reviews. Insufficient number of studies, heterogeneity and lack of pre-registered protocols were the most commonly reported impediments to assessing the biases. In multivariable logistic regression models, both mentioning and formal assessment of publication bias were associated with: inclusion of a meta-analysis; being a review of intervention rather than association studies; higher journal impact factor, and; reporting the use of systematic review guidelines. Assessment of outcome reporting bias was associated with: being an intervention review; authors reporting the use of Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and; inclusion of only controlled trials. Publication bias and outcome reporting bias are infrequently assessed in HSDR systematic reviews. This may reflect the inherent heterogeneity of HSDR evidence and different methodological approaches to synthesising the evidence, lack of awareness of such biases, limits of current tools and lack of pre-registered study protocols for assessing such biases. Strategies to help raise awareness of the biases, and methods to minimise their occurrence and mitigate their impacts on HSDR systematic reviews, are needed.

What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review.

BACKGROUND: In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed. METHODS: A realist review method was adopted involving 3 steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to 3 key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness. RESULTS: A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patientpurchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement. CONCLUSION: Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.

The future of health systems to 2030: a roadmap for global progress and sustainability.

Most research on health systems examines contemporary problems within one, or at most a few, countries. Breaking with this tradition, we present a series of case studies in a book written by key policymakers, scholars and experts, looking at health systems and their projected successes to 2030. Healthcare Systems: Future Predictions for Global Care includes chapters on 52 individual countries and five regions, covering a total of 152 countries. Synthesised, two key contributions are made in this compendium. First, five trends shaping the future healthcare landscape are analysed: sustainable health systems; the genomics revolution; emerging technologies; global demographics dynamics; and new models of care. Second, nine main themes arise from the chapters: integration of healthcare services; financing, economics and insurance; patient-based care and empowering the patient; universal healthcare; technology and information technology; aging populations; preventative care; accreditation, standards, and policy; and human development, education and training. These five trends and nine themes can be used as a blueprint for change. They can help strengthen the efforts of stakeholders interested in reform, ranging from international bodies such as the World Health Organization, the International Society for Quality in Health Care and the World Bank, through to national bodies such as health departments, quality and safety agencies, non-government organisations (NGO) and other groups with an interest in improving healthcare delivery systems. This compendium offers more than a glimpse into the future of healthcare-it provides a roadmap to help shape thinking about the next generation of caring systems, extrapolated over the next 15 years.

Healthcare governance, professions and populism: Is there a relationship? An explorative comparison of five European countries.

A new wave of support for populist parties and movements represents a serious threat to universal healthcare coverage in traditional liberal democracies and beyond. This article aims to contribute empirical material on the relationships between healthcare governance, professions and populism. It applies an explanatory cross-country comparative approach and uses mixed methods, including micro-level data garnered from international comparative databases and documents. Denmark, England, Germany, Italy and Turkey have been selected for comparison, reflecting different types of healthcare systems and populist movements. The results reveal variety in the ways populist discourses impact in healthcare. Abundant economic resources, network-based governance, high levels of trust in healthcare providers and doctors participating as insiders in the policy process seem to work as a bulwark against populist attacks on healthcare and professional expertise. On the other hand, poorly resourced NHS systems with doctors as outsiders in the policy process and major NPM reforms together with low to medium levels of trust in healthcare providers may be fertile ground for populist discourse to flourish. Our explanatory data provide hints of correlations, which may inform further studies to investigate causality. Yet the research highlights that healthcare governance and professions matter, and brings into view capacity for counteracting populist attacks on universal healthcare and professional knowledge.

Accomplishing reform: successful case studies drawn from the health systems of 60 countries.

Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book 'Health Systems Improvement Across the Globe: Success Stories from 60 Countries', we gathered case-study accomplishments from 60 countries. A unique feature of the collection is the diversity of included countries, from the wealthiest and most politically stable such as Japan, Qatar and Canada, to some of the poorest, most densely populated or politically challenged, including Afghanistan, Guinea and Nigeria. Despite constraints faced by health reformers everywhere, every country was able to share a story of accomplishment-defining how their case example was managed, what services were affected and ultimately how patients, staff, or the system overall, benefited. The reform themes ranged from those relating to policy, care coverage and governance; to quality, standards, accreditation and regulation; to the organization of care; to safety, workforce and resources; to technology and IT; through to practical ways in which stakeholders forged collaborations and partnerships to achieve mutual aims. Common factors linked to success included the 'acorn-to-oak tree' principle (a small scale initiative can lead to system-wide reforms); the 'data-to-information-to-intelligence' principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the 'many-hands' principle (concerted action between stakeholders is key); and the 'patient-as-the-pre-eminent-player' principle (placing patients at the centre of reform designs is critical for success).

How to do better health reform: a snapshot of change and improvement initiatives in the health systems of 30 countries.

Health systems are continually being reformed. Why, and how? To answer these questions, we draw on a book we recently contributed, Healthcare Reform, Quality and Safety: Perspectives, Participants, Partnerships and Prospects in 30 Countries. We analyse the impact that these health-reform initiatives have had on the quality and safety of care in an international context-that is, in low-, middle- and high-income countries-Argentina, Australia, Brazil, Chile, China, Denmark, England, Ghana, Germany, the Gulf states, Hong Kong, India, Indonesia, Israel, Italy, Japan, Mexico, Myanmar, New Zealand, Norway, Oman, Papua New Guinea (PNG), South Africa, the USA, Scotland and Sweden. Popular reforms in less well-off countries include boosting equity, providing infrastructure, and reducing mortality and morbidity in maternal and child health. In countries with higher GDP per capita, the focus is on new IT systems or trialling innovative funding models. Wealthy or less wealthy, countries are embracing ways to enhance quality of care and keep patients safe, via mechanisms such as accreditation, clinical guidelines and hand hygiene campaigns. Two timely reminders are that, first, a population's health is not determined solely by the acute system, but is a product of inter-sectoral effort-that is, measures to alleviate poverty and provide good housing, education, nutrition, running water and sanitation across the population. Second, all reformers and advocates of better-quality of care should include well-designed evaluation in their initiatives. Too often, improvement is assumed, not measured. That is perhaps the key message.

Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study.

BACKGROUND: Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. METHODS: Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile. FINDINGS: 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34,350 clinicians surveyed, 15,537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08-1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654). INTERPRETATION: This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme.

A qualitative study of diverse providers' behaviour in response to commissioners, patients and innovators in England: research protocol.

INTRODUCTION: The variety of organisations providing National Health Service (NHS)-funded services in England is growing. Besides NHS hospitals and general practitioners (GPs), they include corporations, social enterprises, voluntary organisations and others. The degree to which these organisational types vary, however, in the ways they manage and provide services and in the outcomes for service quality, patient experience and innovation, remains unclear. This research will help those who commission NHS services select among the different types of organisation for different tasks. RESEARCH QUESTIONS: The main research questions are how organisationally diverse NHS-funded service providers vary in their responsiveness to patient choice, NHS commissioning and policy changes; and their patterns of innovation. We aim to assess the implications for NHS commissioning and managerial practice which follow from these differences. METHODS AND ANALYSIS: Systematic qualitative comparison across a purposive sample (c.12) of providers selected for maximum variety of organisational type, with qualitative studies of patient experience and choice (in the same sites). We focus is on NHS services heavily used by older people at high risk of hospital admission: community health services; out-of-hours primary care; and secondary care (planned orthopaedics or ophthalmology). The expected outputs will be evidence-based schemas showing how patterns of service development and delivery typically vary between different organisational types of provider. ETHICS, BENEFITS AND DISSEMINATION: We will ensure informants' organisational and individual anonymity when dealing with high profile case studies and a competitive health economy. The frail elderly is a key demographic sector with significant policy and financial implications. For NHS commissioners, patients, doctors and other stakeholders, the main outcome will be better knowledge about the relative merits of different kinds of healthcare provider. Dissemination will make use of strategies suggested by patient and public involvement, as well as DH and service-specific outlets.

Challenges in Achieving Collaboration in Clinical Practice: The Case of Norwegian Health Care.

INTRODUCTION: This article summarizes and synthesizes the findings of four separate but inter-linked empirical projects which explored challenges of collaboration in the Norwegian health system from the perspectives of providers and patients. The results of the four projects are summarised in eight articles. METHODS: The eight articles constituted our empirical material. Meta-ethnography was used as a method to integrate, translate, and synthesize the themes and concepts contained in the articles in order to understand how challenges related to collaboration impact on clinical work. RESULTS: Providers' collaboration across all contexts was hampered by organizational and individual factors, including, differences in professional power, knowledge bases, and professional culture. The lack of appropriate collaboration between providers impeded clinical work. Mental health service users experienced fragmented services leading to insecurity and frustration. The lack of collaboration resulted in inadequate rehabilitation services and lengthened the institutional stay for older patients. CONCLUSION: Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration. Organizational systems need to be redesigned to better nurture collaborative relationships and information sharing and support integrated working between providers, health care professionals and patients.

The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme.

OBJECTIVES: Performance measurement systems are increasingly used to reward and improve provider performance. However, such initiatives may also inadvertently induce a range of unintended and dysfunctional side-effects. This study explores the unintended and adverse consequences induced by the Iranian national hospital grading programme, which incorporates financial incentives for meeting nationally defined standards. METHODS: We interviewed key informants across four key groups with a legitimate interest in healthcare performance: four purposively selected hospitals; four health insurance organizations; the Iranian hospital accreditation body; and one grading agency. The transcribed interviews and field notes were analysed thematically, and subsequently, member checking was conducted. RESULTS: Seven dysfunctional consequences were identified: misrepresentation of data by hospitals; increased anxiety and stress among hospital employees; tunnel vision; financial pressures on poorly graded hospitals; incentives to purchase unnecessary equipment; erosion of public trust; and restricting access to hospital services by patients. These were caused by the way the grading system was implemented: poor standards of audit; the way in which the audit process was conducted; and the timing of audits. The pay for performance element of the grading system and the focus on structural aspects in the standards made improvement in grading particularly difficult for those hospitals that had been assessed as under-performing. CONCLUSION: Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.

Take the money and run: the challenges of designing and evaluating financial incentives in healthcare; Comment on "Paying for performance in healthcare organisations".

Many countries are turning their attention to the use of explicit financial incentives to drive desired improvements in healthcare performance. However, we have only a weak evidence-base to inform policy in this area. The research challenge is to generate robust evidence on what financial incentives work, under what circumstances, for whom and with what intended and unintended consequences.