Currently, in Ferrara University Hospital there is not a system of balanced measurement of performance. Numerous objectives, to be reached within the year, are defined for every department. Usually the objectives are classified in two types: economic and organizational and they are arranged between the direction and the department. A specific indicator for each objective has been defined. The global performance of Operating Unit (UO) has never been measured. The economic objectives have a great weight in comparison to the organizational objectives.
Taking the context and the inescapable constraints (regulation, indications, organisation and resources) into account, a series of objectives and tasks was defined via multi-dimensional analysis.
A monitoring system comprising specific, previously identified indicators (the panel) consented awareness and modulation of the performance, progress and implementation of the plan .
The structure of the strategic map and the importance submitted to the analyzed perspectives, are the principal differences between the managerial model born in Private Firms and the public hospitals system. The division into the four classical perspectives remains, but a different vision of the priorities must be produced. If in a private firm the financial economic perspective has a primary role, in health care service the patient and the community have primary importance. The satisfaction of necessities and requests is the first objective.
With the collaboration of the health workers, a precise methodological procedure was pursued:
Definition of the strategic map, divided into 4 perspectives according to Kaplan and Norton :
The community perspective: it defines the value which the health care service proposes to the community. The relationship between community and sanitary organization show numerous facets. The public health service must find all these relationships.
The community perspective was further subdivided into:
Clients as Users: it represents the individual and direct relationship between the Clients and the organization.
Clients as Owners: Clients are the "Owners" of the public service. They can verify the results of strategies, policy and quality assurance, favouring the continuous improvement of resources allocation.
Clients as Public entities: The application of the norms and the laws protects the community and the environment to the purpose to improve the relationship with the performance of sanitary organization.
The objectives defined in these three dimensions improve the description of the meaning of the community perspective
The internal procedure perspective: Through the internal procedure perspective the specific procedures are individualized and performed for Clients as Users, Clients as Owners and Clients as Public entities. An objective of the internal procedure perspective can have a direct influence on the community perspective.
The financial perspective: In Public Healt Service, the financial resources represent some ties inside which the organization must operate. It is a primary tool of the efficiency. The Budget result is the first objective of the financial perspective
The growth and learning perspective: The growth and learning perspective describes the "intangible wealth" of the sanitary organization.
The growth and learning perspective was divided into:
Human resources: all the competences and the necessary abilities to correctly perform the strategy
Information resources: all the procedures and the computer infrastructure to support the necessary informative flows to take effective decisions
Organisational resources: the business culture, the leadership, the ability to work in team, the alignment of the organization with the strategy.
In our study, the growth and learning perspective needs further specific researches to define other objectives and indicators (in particular the Information resources). During 2007 a specific indicator for the continuous improvement of ICT, especially in the relationships with GPs, has been proposed. This study will be completed during the 2008.
In the case of the Analysis Laboratory Operating Unit (OU), "user" did not only refer to the patient, but also to the other entities availing themselves of the services of the OU on a daily basis, such as GPs and hospital physicians.
Definition of the Key Performance Areas (KPA) or macro-objectives, i.e. the most important fields in which to measure the performance levels, linking them to the perspectives identified .
Determination of the cause/effect relationships between the KPAs: in this way it's possible to understand the connection between the realization of the objectives of a performance area and the realization of another area. This factor shows the interdependence inside our public hospitals system.
Indication, for each KPA, of the pre-established sub-objectives required by the OU to fulfil the KPAs.
Definition of the Key Performance Indicators (KPI) to monitor the degree of achievement of the performance levels defined for each KPA.
Based on the above information and criteria, indicators, and consequently specific objectives, were produced, classified into common areas such as measurability, reliability, practicability, sustainability and relevance.
The data were organised in a spreadsheet as follows:
○ 1st column: macro-objective defined in the strategic map;
○ 2nd column: pre-established sub-objectives - mainly objectives from areas in which the services were already dealing with: budget, credit, performance indicators;
○ 3rd column: definition of the indicator for evaluating the achievement of the objective (clarification of the previous point);
○ 4th column: value found;
○ 5th column: standard/expected value. The standard value represented the acceptable threshold, i.e. that which defined the upper and lower-most limits of adequate quality of assistance. In this study, the standard was established in agreement with the health workers, either by analysing reported data or based on the previous experience of the OU. In the case of new measures which cannot not be based on previous experience or reports, in future it could be necessary to readjust the fixed standard to bring it in line with operative reality;
○ 6th column: weight/importance to attribute to each objective; the sum of weights for each perspective was equal to 100. In order to define the weight it was decided to consider the mean weight for each indicator supplied by a pool of professionals (opportunely involved) from various sectors: assistance, organisational, directional. The attribution of a weight to each objective permitted balanced evaluation of OU activity, highlighting the key objectives of the relevant perspective;
○ 7th column: means of detection. The data were revealed either by information systems, directly from the employee or from specific informative sources (Quality Assurance Office, Medical Direction, Mixed Advisory Committee, Public Relations Office and/or Management Control);
○ 8th column: frequency of data acquisition.
In order to evaluate the results for each perspective, the fundamental data were grouped and summarised in one table. The evaluation panel was made up of 5 of these tables, one for each perspective and one summarising the progress of the OU as a whole.
The achievement of objectives was graphically represented as a traffic light as follows:
○ Red: objective not achieved
○ Green: objective achieved
○ Amber: "borderline" conditions:
The data for the Digestive Endoscopy OU were obtained in 2007.
Those for the Analysis Laboratory OU were partly obtained in 2007, and partly in the first six months of 2008: in fact, some indicators refer to activities not implemented prior to 2008.
In order to arrive at an overall performance value for each perspective, the weights of the various objectives of each perspective were added and translated into a traffic light, the colour of which represents the prevalent colour obtained. These indications of global achievement are presented in the summary table of each OU.
Centre for Digestive Endoscopy
Additional file 1 shows the strategic map elaborated for the Digestive Endoscopy Unit, highlighting the macro-objectives and cause-effect relationships.
Additional files 2, 3, 4, 5 show and describe the specific objectives, the indicators, the observed values, the standard, and the weight for each perspective.
Additional file 6 shows the strategic map elaborated for the Analysis Laboratory highlighting the macro-objectives and the cause-effect relationships.
Additional files 7, 8, 9, 10 show and describe the specific objectives, the indicators, the observed values, the standard, and the weight for each perspective.
Additional files 11 and 12 show the EVALUATION PANEL. containing the level of performance of each perspective of the Centre for Digestive Endoscopy and the Analysis Laboratory respectively.