Background: The use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners. Methods: The aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation. Results: A continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a ‘positive narration’ of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals’ levels. Conclusions: The PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours.

Current performance measurement systems (PMSs) are mainly designed to measure performance at the organizational level. They tend not to assess the value created by the collaboration of multiple organizations and by the involvement of users in the value creation process, such as in healthcare. The purpose of this paper is to investigate the development of PMSs that can assess the population-based value creation process across multiple healthcare organizations while adopting a patient-based perspective. The paper analyzes the development of a new healthcare PMS according to a constructive approach through the development of a longitudinal case study. The focus is on the re-framing process of the PMS put in place by a large group of Italian regional health systems that have adopted a collaborative assessment framework. Framing information according to the population served and the patients’ perspective supports PMSs in assessing the value creation process by evaluating the contribution given by the multiple organizations involved. Therefore, it helps prevent each service provider from working in isolation, and avoids dysfunctional behaviors. Re-framing PMSs contributes to re-focusing stakeholders’ perspective toward value creation; legitimizes organizational units specifically aimed at managing transversal communication, cooperation and coordination; supports the alignment of professionals’ and organizations’ goals and behaviors; and fosters shared accountability among providers. The paper contributes to the scientific debate on PMSs by investigating a case that focuses on value creation by adopting a patient-centered perspective. Although this case comes from the healthcare sector, the underlying user-centered approach may be generalized to assess other environments, processes, or contexts in which value creation stems from the collaboration of multiple providers (integrated co-production).

This paper reports the measurement of technical efficiency of Tuscan Local Health Authorities and its relationship with quality and appropriateness of care. First, a bias-corrected measure of technical efficiency was developed using the bootstrap technique applied to data envelopment analysis. Then, correlation analysis was used to investigate the relationships among technical efficiency, quality and appropriateness of care. These analyses have been applied to the Local Health Authorities of Tuscany Region (Italy), which provide not only hospital inpatient services, but also prevention and primary care. All top managers of Tuscan Local Health Authorities were involved in selection of the inputs and outputs for calculating technical efficiency. The main measure used in this study are volume, quality and appropriateness indicators monitored by the multidimensional performance evaluation system developed in the Tuscany Region. On average, Tuscan Local Health Authorities experienced 14(%) of bias-corrected inefficiency in 2007. Correlation analyses showed a significant negative correlation between per capita costs and overall performance. No correlation was found in 2007 between technical efficiency and overall performance or between technical efficiency and per capita costs. Technical efficiency cannot be considered as an extensive measure of healthcare performance, but evidence shows that Tuscan Local Health Authorities have room for improvement in productivity levels. Indeed, correlation findings suggest that, to pursue financial sustainability, Local Health Authorities mainly have to improve their performance in terms of quality and appropriateness.

As diabetic foot (DF) care benefits from integration, monitoring geographic variations in lower limb Major Amputation rate enables to highlight potential lack of Integrated Care. In Tuscany (Italy), these DF outcomes were good on average but they varied within the region. In order to stimulate an improvement process towards integration, the project aimed to shift health professionals' focus on the geographic variation issue, promote the Population Medicine approach, and engage professionals in a community of practice. Three strategies were thus carried out: the use of a transparent performance evaluation system based on benchmarking; the use of patient stories and benchmarking analyses on outcomes, service utilization and costs that cross-checked delivery- and population-based perspectives; the establishment of a stable community of professionals to discuss data and practices. The project enabled professionals to shift their focus on geographic variation and to a joint accountability on outcomes and costs for the entire patient pathways. Organizational best practices and gaps in integration were identified and improvement actions towards Integrated Care were implemented. For the specific category of care pathways whose geographic variation is related to a lack of Integrated Care, a comprehensive strategy to improve outcomes and reduce equity gaps by diffusing integration should be carried out.

Summary: Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision‐making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence‐based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness.Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks.Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country.As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.

Hybrid professionals have a two-fold – professional and managerial – role, which requires appropriate management skills. Investing on managerial training programs aims to empower professionals with managerial skills and competencies. Does this pay back? Assessing the impact of such training programs is still a limited practice. This paper explores whether participation in managerial training programs in healthcare can enhance the involvement of hybrid professionals (namely, clinical directors) in top management decision-making. The mediational effects of knowledge of performance information and its use are explored. Survey data were collected from more than 3000 clinical directors of 69 public health authorities from five regional healthcare systems in Italy. Relationships between participation in managerial training programs, performance management practices (i.e., knowledge and use of performance information) and the level of clinicians’ involvement by the top management were studied using a three-path mediation analysis with structural equation modelling. Propensity score matching was also performed to mitigate selection bias. Knowledge and use of performance information positively mediate, both independently and sequentially, the relationship between clinical directors' participation in managerial training programs and the level of their involvement in decision-making. The results of the study suggest that managerial training can support hybrid professionals in engaging with managerialism and playing upward influence on top management decision-making.