Context and background
Performance measurement and evaluation systems are important governance tools within health care systems: they support decision-making, planning and control processes, and they stimulate and guide continuous quality improvement. Both at the international level (for example, OECD) and at the national level (for example, the National Outcomes Programme in Italy), there is a wealth of experience and approaches for developing multidimensional evaluation systems. These encompass a variety of objectives that can be measured by specific indicators.
Evaluating the performance of health services is one of the institutional tasks of AGENAS (National Agency for Regional Health Services), serving as the technical-scientific agency of the Italian National Health Service (Servizio Sanitario Nazionale, SSN). The Agency carries out research and support activities for the Minister of Health and the regions.
With the 2019 budget law (Law 30 December 2018, no. 145), AGENAS was tasked with developing a new multidisciplinary monitoring system to support the Ministry of Health, the regions and the autonomous provinces, specifically “[... A system for analysing and monitoring the performance of public Local Health Authorities and Hospital Trusts, which, by means of a specific warning mechanism, will signal, in a preventive manner, any significant deviation in the economic-management, organizational, financial and accounting, clinical-support, clinical-effectiveness and diagnostic-therapeutic process components, the quality, safety and outcome of care, as well as the equity and transparency of processes [ . . . ]”.
The new system of performance evaluation
The new system introduced by the Agency started with the evaluation of (public) Hospital Trusts from an organizational-management and economic-financial perspective, in addition to the evaluation of the quality of healthcare from a clinical-support standpoint, which is already monitored by the National Outcomes Programme. Assessing these new dimensions can help healthcare organizations improve patient safety, ensure clinical and organizational appropriateness, and reduce both errors and wasted resources.
Inspired by Donabedian’s quality measurement model, the evaluation includes three key areas of performance measurement: structure, process and outcome. While the process and outcome dimensions reflect the National Outcomes Programme summaries, the structure dimension introduces a new element of analysis. Specifically, it encompasses five performance areas: i) accessibility; ii) organizational process governance; iii) financial sustainability; iv) workforce; and v) investment. Each is further broken down into sub-areas and related indicators (Randazzo & Guerrieri, 2023).
The Agency’s monitoring model, in compliance with Legislative Decree No. 171 of 2016, also strengthens the importance of healthcare management and organization. It stipulates that public Hospital Trusts’ General Managers must be evaluated on the basis of the achievement of the health and service operation objectives set by regional planning. This new system will be essential both for the regions and their governance toolkits, enabling the evaluation of Hospital Trust management performance, and at the Hospital Trust level, for internal management purposes, facilitating monitoring the performance of its operations, identifying critical areas and areas for development, all of which feed into the continuous process of management improvement.
AGENAS has developed an easily accessible online portal to promote adoption of the monitoring model. This platform facilitates the evaluation of the performance of healthcare organizations on several levels with different “views”, over time and space. It also allows organizations to monitor their performance trends.