Tracking the digital health gap in elderly: A study in Italian remote areas.

The Covid-19 pandemic has provided a major innovative thrust to public services regarding their digitization to continue providing an effective response to the population's needs and to reduce management costs. However, there has been a partial lack of those welfare policies that can provide an adequate response to the elderly segment of the population, which is most affected by the introduction of new technologies into the public sphere. This study analyses the digital gap in health in the elderly living in remote areas of Italy and investigates the use of digital devices for health purposes. It compares the use of digital solutions for health with people's common digital competencies and their willingness to use them. A descriptive analysis of the sample was constructed to verify the different responses of the elderly by age, gender, educational qualification, and geographic area. Furthermore, regression analyses have been conducted to test whether there is any dependent effect among the elderly's characteristics or geographic areas. The results highlight the existence of a potential digital health gap among the elderly in remote areas of Italy both due to infrastructural issues and the lack of digital skills. The latter are positively correlated with educational qualification, such that it is also possible to highlight differences between age groups analysed and shape future welfare policies to reduce digital inequality.

The management of healthcare employees' job satisfaction: optimization analyses from a series of large-scale surveys.

BACKGROUND: Measuring employees' satisfaction with their jobs and working environment have become increasingly common worldwide. Healthcare organizations are not extraneous to the irreversible trend of measuring employee perceptions to boost performance and improve service provision. Considering the multiplicity of aspects associated with job satisfaction, it is important to provide managers with a method for assessing which elements may carry key relevance. Our study identifies the mix of factors that are associated with an improvement of public healthcare professionals' job satisfaction related to unit, organization, and regional government. Investigating employees' satisfaction and perception about organizational climate with different governance level seems essential in light of extant evidence showing the interconnection as well as the uniqueness of each governance layer in enhancing or threatening motivation and satisfaction. METHODS: This study investigates the correlates of job satisfaction among 73,441 employees in healthcare regional governments in Italy. Across four cross sectional surveys in different healthcare systems, we use an optimization model to identify the most efficient combination of factors that is associated with an increase in employees' satisfaction at three levels, namely one's unit, organization, and regional healthcare system. RESULTS: Findings show that environmental characteristics, organizational management practices, and team coordination mechanisms correlates with professionals' satisfaction. Optimization analyses reveal that improving the planning of activities and tasks in the unit, a sense of being part of a team, and supervisor's managerial competences correlate with a higher satisfaction to work for one's unit. Improving how managers do their job tend to be associated with more satisfaction to work for the organization. CONCLUSIONS: The study unveils commonalities and differences of personnel administration and management across public healthcare systems and provides insights on the role that several layers of governance have in depicting human resource management strategies.

Integrating Key Nursing Measures into a Comprehensive Healthcare Performance Management System: A Tuscan Experience.

This paper addresses the evaluation of nursing quality and safety beyond nursing tasks in specific healthcare settings and sets it in a context that conveys the sense of complexity and multifaceted nature of the contribution that nursing makes to the whole system. The paper describes research conducted in Tuscany during 2019 involving regional managers and heads of nursing departments. This research has led to the development of an integrated evaluation framework through focus groups and consensus process with the latter, which includes Performance Organizational climate data, Patient-Reported Experience Measures (PREMs), and Patient-Reported Outcome Measures (PROMs). This integrated framework aims at both making sense of extant measures as key performance indicators shared among different professionals while recognizing the important role of nursing care by adding specific measures and can be seen as a tool that boosts the sense of "teamness" in healthcare.

The Challenges of Hospitals' Planning & Control Systems: The Path toward Public Value Management.

In the last decades, public management has been subjected to a shift from the New Public Management (NPM) paradigm to the Public Value Management (PVM) one. Thus, management practices such as Planning and Control (P&C) systems have been called to evolve accordingly. The health care sector has not escaped this process. This paper focuses on the evolution of hospitals' P&C systems to support the paradigm shift from the NPM paradigm to the PVM one. In particular, the paper aims at exploring whether hospitals' P&C systems in Italy evolved, or are evolving, consistently with PVM and what are the expected benefits related to such a paradigm switch. To address the research aim, the paper is based on a review of scientific and grey literature and the case study of the diabetic-foot pathway in an Italian Regional Healthcare System. The results of this study show that the current P&C systems in Italian hospitals are not yet designed to support the shift toward the PVM approach and are still mainly focused on financial aspects and intra-organizational dynamics. Combining traditional P&Cs with performance measures assessing the system's outcomes may support hospitals in aligning their goals with the health system they are operating within and, therefore, P&C systems may represent an important driving force toward change. Such results provide suggestions for both practitioners and academics on how to adapt P&C systems to better support the implementation of current strategies of the public sector.

Research protocol for the validation of a new portable technology for real-time continuous monitoring of Early Warning Score (EWS) in hospital practice and for an early-stage multistakeholder assessment.

INTRODUCTION: The real-time continuous monitoring of vital parameters in patients affected by multiple chronic conditions and/or COVID-19 can lead to several benefits to the Italian National Healthcare System (IT-NHS). The UBiquitous Integrated CARE (UBICARE) technology is a novel health digital platform at the validation stage in hospital setting. UBICARE might support the urgent need for digitalisation and early intervention, as well as minimise the face-to-face delivery of care in both hospital and community-based care settings. This research protocol aims to design an early-stage assessment of the multidimensional impact induced by UBICARE within the IT-NHS alongside technology validation in a hospital ward. METHODS AND ANALYSIS: The targeted patients will be medium/high-risk hypertensive individuals as an illustrative first example of how UBICARE might bring benefits to susceptible patients. A mixed-method study will be applied to incorporate to the validation study a multistakeholder perspective, including perceived patient experiences and preferences, and facilitate technology adoption. First, semistructured interviews will be undertaken with a variety of stakeholders including clinicians, health managers and policy-makers to capture views on the likely technology utility, economic sustainability, impact of adoption in hospital practice and alternative adoption scenarios. Second, a monocentric, non-randomised and non-comparative clinical study, supplemented by the administration of standardised usability questionnaires to patients and health professionals, will validate the use of UBICARE in hospital practice. Finally, the results of the previous stages will be discussed in a multidisciplinary-facilitated workshop with IT-NHS relevant stakeholders to reconcile stakeholders' perspectives. Limitations include a non-random recruitment strategy in the clinical study, small sample size of the key stakeholders and potential stakeholder recruitment bias introduced by the research technique. ETHICS AND DISSEMINATION: The Ethics Committee for Clinical Experimentation of Tuscany Region approved the protocol. Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.

A Performance Management System in Healthcare for All Seasons?

Health systems face challenges which are inherent to care demand and supply evolution (i.e., demographic change, new technologies) or are the results of unexpected occurrence originating outside the health system, such as economic shocks or epidemic outbreaks. Both challenges often require a paradigm shift in governance and organization, financing and resource allocation, accountability frameworks, as well as public health system responses. Based on key reviews and seminal papers of performance management, public health, sustainability and resilience, the article presents three emerging challenges for performance management systems in healthcare: i) the inclusion of the population approach; ii) the measurement and consideration of the multi-facets concepts of value; iii) the importance of resilience and sustainability. Performance management systems need to evolve to cope with this changing scenario. The article sheds light on uncovered areas by performance management, and it proposes a research agenda for scholars of both performance management and health service research.

Waiting times in emergency departments: a resource allocation or an efficiency issue?

BACKGROUND: In recent years, the flow of patients to the Emergency Departments (ED) of Western countries has steadily increased, thus generating overcrowding and extended waiting times. Scholars have identified four main causes for this phenomenon, related to: continuity of primary care services; availability of specific clinical pathways for chronic patients; ED's personnel endowment; organization of the ED. This study aims at providing a logical diagnostic framework to support managers in investigating specific solutions to be applied to their EDs to cope with high ED waiting times. The framework is based on the ED waiting times and ED admission rate matrix. It was applied to the Tuscan EDs as illustrative example. METHODS: To provide the factors to be analyzed once the EDs are positioned into the matrix, a list of issues has been identified. The matrix was applied to Tuscan EDs. Data were collected from the Tuscan performance evaluation system, integrated with specific data on Tuscan EDs' personnel. The Tuscan EDs matrix, the descriptive statistics for each quadrant and the Spearman's rank correlation analysis among waiting times, admission rates and a set of performance indicators were conducted to help managers to read the phenomena that they need to investigate. RESULTS: The combined reading of the correlations and waiting times-admission rates matrix shows that there are no optimal rules for all the EDs in managing admission rates and waiting times, but solutions have to be found considering mixed and personalized strategies. CONCLUSIONS: The waiting times-admission rates matrix provides a tool able to support managers in detecting the problems related to the management of ED services. In particular, using this matrix, healthcare managers could be facilitated in the identification of possible solutions for their specific situation.

Unintended consequences of expenditure targets on resource allocation in health systems.

In recent decades, several countries have reformed their health care systems leading to the devolution of power to a lower governance level and, subsequently, to re-centralisation. Due to the ambiguous results of these policies and the start of the financial crisis of 2008, a wide number of national governments implemented cutback initiatives aimed at controlling health expenditure. The literature shows that the introduction of such initiatives may have produced unintended consequences on health systems' performance. In order to better understand the power relations and the resulting decision-making processes between national governments and local authorities, it is important to focus on the effects of such expenditure control mechanisms on the inputs of the health systems, i.e. the production factors. This research aims at investigating the effects of a cutback initiative intended to control personnel costs in a federal Beveridge health system through the analysis of resource allocation at the devolved level. The paper is based on a quantitative analysis of data resulting from the financial statements published by the 21 Italian regional health systems from 2012 to 2017. The results show that, although the Italian regional health systems managed to reduce personnel costs - i.e. hitting the target - the control of the total cost dynamic was not fully addressed. Overall, the initiative implemented by the national government had the effect of limiting the decision-making autonomy of regional authorities, pushing them toward shifting resource allocation from personnel to the purchase of services.

The role of collective labor contracts and individual characteristics on job satisfaction in Tuscan nursing homes.

BACKGROUND: The role played by remuneration strategies in motivating health care professionals is one of the most studied factors. Some studies of nursing home (NH) services, while considering wages and labor market characteristics, do not explicitly account for the influence of the contract itself. PURPOSE: This study investigates the relationship between the labor contracts applied in 62 Tuscan NHs and NH aides' job satisfaction with two aims: to investigate the impact of European contracts on employee satisfaction in health care services and to determine possible limitations of research not incorporating these contracts. METHODOLOGY: We apply a multilevel model to data gathered from a staff survey administered in 2014 to all employees of 62 NHs to analyze two levels: individual and NH. Labor contracts were introduced into the model as a variable of NH. RESULTS: Findings show that the factors influencing nursing aides' satisfaction occur at both the individual and NH levels. Organizational characteristics explain 16% of the variation. For individual characteristics, foreign and temporary workers emerge as more satisfied than others. For NH variables, results indicate that the labor contract with the worst conditions is not associated with lower workers' satisfaction. CONCLUSION: Although working conditions play a relevant role in the job satisfaction of aides, labor contracts do not seem to affect it. Interestingly, aides of the NHs with the contract having the best conditions register a significantly lower level of satisfaction compared to the NHs with the worst contract conditions. This suggests that organizational factors such as culture, team work, and other characteristics, which were not explicitly considered in this study, may be more powerful sources of worker satisfaction than labor contracts. PRACTICE IMPLICATIONS: Our analysis has value as a management tool to consider alternative sources as well as the labor contract for employee incentives.

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries.

AIM: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. BACKGROUND: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. METHODS: Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. FINDINGS: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. CONCLUSIONS: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

Explaining performance in health care: How and when top management competencies make the difference.

BACKGROUND: One of the most distinctive management competencies is related to the ability to structure the strategic vision, develop long-term plans, and communicate them efficiently to the employees in order to empower them to enact. These managerial competencies in complex organizations are strongly related to the capacity to engage professionals as a predictor of high-performing organizations. PURPOSE: The aim of this study was to investigate the relationship between top management competencies, information sharing, and organizational performance in public health care system and to look at the management role in assuring information sharing on organizational strategies to achieve professionals' engagement. METHODOLOGY/APPROACH: This relationship is empirically tested using the longitudinal data of public health care organizations from the Tuscany Region (Italy). The top management competencies and information sharing are evaluated by the heads of the departments. While information sharing refers to the organizational level (e.g., to convey the objectives), managerial competencies refer to the individual level (e.g., to manage conflict). A random effect regression model is estimated using average responses by the health organization. Data come from the multidimensional performance evaluation system (2008 to 2014 years). RESULTS: Findings show that managerial competencies are positively associated to organizational performance. Moreover, managerial competencies are strongly linked to the information sharing process developed into the organizations. In particular, managerial competencies play a significant role on whole performance, and results are mediated by the use of mature information sharing instruments such as benchmarking of performance results. CONCLUSION: Systematic information sharing process regarding performance results, goals, and organizational structure provided by top management seems an effective strategy to engage professionals. Control variables suggest that top management tenure and turnover do not have an effect, whereas bigger health care organizations seem to negatively influence this relation. PRACTICE IMPLICATIONS: Information sharing is the basis for clinicians' engagement and adds value to organizational performance.

A turnaround strategy: improving equity in order to achieve quality of care and financial sustainability in Italy.

BACKGROUND: Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities. METHODS: The analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap. RESULTS: All indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits. CONCLUSIONS: Reducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.

Insights on the effectiveness of reward schemes from 10-year longitudinal case studies in 2 Italian regions.

BACKGROUND: Pay for performance (P4P) programs have been widely analysed in literature, and the results regarding their impact on performance are mixed. Moreover, in the real-life setting, reward schemes are designed combining multiple elements altogether, yet, it is not clear what happens when they are applied using different combinations. OBJECTIVES: To provide insights on how P4P programs are influenced by 5 key elements: whom, what, how, how many targets, and how much to reward. METHODS: A qualitative longitudinal analysis of 10 years of P4P reward schemes adopted by the regional administrations of Tuscany and Lombardy (Italy) was conducted. The effects of the P4P features on performance are discussed considering both overall and specific indicators. RESULTS: Both regions applied financial reward schemes for General Managers by linking the variable pay to performance. While Tuscany maintained a relatively stable financial incentive design and governance tools, Lombardy changed some elements of the design and introduced, in 2012, a P4P program aimed to reward the providers. The main differences between the 2 cases regard the number of targets (how many), the type (what), and the method applied to set targets (how). CONCLUSION: Considering the overall performance obtained by the 2 regions, it seems that whom, how, and how much to reward are not relevant in the success of P4P programs; instead, the number (how many) and the type (what) of targets set may influence the performance improvement processes driven by financial reward schemes.

Patient-perceived responsiveness of primary care systems across Europe and the relationship with the health expenditure and remuneration systems of primary care doctors.

BACKGROUND: Health systems are expected to be responsive, that is to provide services that are user-oriented and respectful of people. Several surveys have tried to measure all or some of the dimensions of the responsiveness (e.g. autonomy, choice, clarity of communication, confidentiality, dignity, prompt attention, quality of basic amenities, and access to family and community support), however there is little evidence regarding the level of responsiveness of primary care (PC) systems. METHODS: This work analyses the capacity of primary care systems to be responsive. Data collected from 32 PC systems were used to investigate whether a relationship exists between the responsiveness of PC systems and the PC doctor remuneration systems and domestic health expenditure. RESULTS: There appears to be a higher responsiveness of PC when doctors are paid via capitation than when they only receive a fee for services or a mixed payment method. In addition, countries that spend more on health services are associated with higher levels of dignity and autonomy. CONCLUSION: Quality, as measured from the patient's perspective, does not necessarily overlap with PC performance based on structure and process indicators. The results could also stimulate a new debate on the role of economic resources and PC workforce payment mechanisms in the achievement of quality goals, in this case related to the capacity of PC systems to be responsive.

How to set challenging goals and conduct fair evaluation in regional public health systems. Insights from Valencia and Tuscany Regions.

The definition of "the right targets" and the way the evaluation of results is performed affect the willingness to commit to new challenges, which is a factor that influences the relationship between goal setting and performance results. Indeed, some authors claim that the choice of an inappropriate goal-setting procedure is a major cause of failure of management control systems. Goal setting theorists found that assigning a specific and challenging goal leads to higher performance than (a) an easy goal, (b) a general goal or (c) no goal setting. Despite this evidence, yet, few proposals concern the definition of what is "challenging". This paper focuses on two issues: (a) what is to be considered a challenging goal and (b) what is a "fair evaluation" in the health care sector. This work suggests that benchmarking is a valid support to solve the previous dilemmas. Relying on two Regional European advanced experiences - Valencia in Spain and Tuscany in Italy -, this paper aims to provide conceptual methods that can help managers define challenging goals and conduct fair evaluation about their achievement. Although these Regions adopted different governance models, both of them applied very similar techniques, which seem to be associated to an improvement of their performance and a reduction of unwarranted variation.

Making governance work in the health care sector: evidence from a 'natural experiment' in Italy.

The Italian Health care System provides universal coverage for comprehensive health services and is mainly financed through general taxation. Since the early 1990s, a strong decentralization policy has been adopted in Italy and the state has gradually ceded its jurisdiction to regional governments, of which there are twenty. These regions now have political, administrative, fiscal and organizational responsibility for the provision of health care. This paper examines the different governance models that the regions have adopted and investigates the performance evaluation systems (PESs) associated with them, focusing on the experience of a network of ten regional governments that share the same PES. The article draws on the wide range of governance models and PESs in order to design a natural experiment. Through an analysis of 14 indicators measured in 2007 and in 2012 for all the regions, the study examines how different performance evaluation models are associated with different health care performances and whether the network-shared PES has made any difference to the results achieved by the regions involved. The initial results support the idea that systematic benchmarking and public disclosure of data are powerful tools to guarantee the balanced and sustained improvement of the health care systems, but only if they are integrated with the regional governance mechanisms.

Healthcare resources and expenditure in financial crisis: scenarios and managerial strategies.

OBJECTIVE: What are the implications of financial crisis on healthcare expenditure? This paper explores different approaches applied across European countries focusing on the role that managerial tools may have in coping with this challenge. METHOD: The paper reports the results of recent studies on responses to financial crisis from European countries and which are the techniques they had applied to reallocate resources. RESULTS: Although resources scarcity, some governments did not reduce the healthcare expenditure because they believe in its focal role on the economic development and on maintaining social cohesion and protection of vulnerable people. Other countries decided a strong reduction of costs which often has affected services delivered. In both cases authors suggest to avoid across-the-board cuts in favor of approach involving priority setting. CONCLUSION: The public sector has assumed new responsibilities following the global crisis and the rising demand for social services. Some countries shifted the healthcare costs from the public purse to private households undermining the survival of the health system and the universal coverage. A way to avoid this risk is based on the ability to share discussion about where to cut and where to reallocate resources.

Assessment and improvement of the Italian healthcare system: first evidence from a pilot national performance evaluation system.

The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.

QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care.

BACKGROUND: The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described. METHODS/DESIGN: QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models. DISCUSSION: By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.

Disinvestment for re-allocation: a process to identify priorities in healthcare.

Resource scarcity and increasing service demand lead health systems to cope with choices within constrained budgets. The aim of the paper is to describe the study carried out in the Tuscan Health System in Italy on how to set priorities in the disinvestment process for re-allocation. The analysis was based on 2007 data benchmarking of the Tuscan Health System with an impact on the level of resources used. For each indicator, the first step was to estimate the gap between the performance of each Health Authority (HA) and the best performance or the regional average. The second step was to measure this gap in terms of financial value. The results of the analysis demonstrated that, at the regional level, 2-7% of the healthcare budget can be re-allocated if all the institutions achieve the regional average or the best practice. The implications of this study can be useful for policy makers and the HA top management. In the context of resource scarcity, it allows managers to identify the areas where the institutions can achieve a higher level of efficiency without negative effects on quality of care and instead re-allocate resources toward services with more value for patients.