Designing performance measurement systems in health care: multiple organizational players and their interaction in the case of the prevention services in tuscany

The designing of a performance measurement system usually involves several players, the number and the role of the players in building new performance measurement tools depending on the features affecting the type of organization. Among them, health care units can be considered as some of the most complex to manage (“Running even the most complicated corporation must sometimes seem like child’s play compared to trying to manage almost any hospital.”, Mintzberg and Glouberman 2001), being based on professionals’ activity. Professionals play a wide span of autonomy and they can resist towards changes and control systems that do not involve them, thus implicating their deep involvement in designing and implementing effective management control devices. Due to this characteristic, the decision makers about measurement systems in public health are not only the politics and top managers at different levels (national, regional and local) but also the professionals at their level. But which are the roles of these players at their organizational levels? Do they play a different role in desing and implementation of a performance measurement system? And which are the interactions among them? The aim of this paper is to answer at these questions through the experience of the design of the so-called Prodotti Finiti system for measuring output and performance of the prevention services in Tuscan health care system. The necessity of this performance measurement system rises from a lack that regards the primary care and the collective prevention services: while in the hospital services the DRGs system has been developed and used as a shared tool to measure output and performance, in the primary care and the collective prevention services there is no shared and uniform way to measure the services provided. The idea of using the Prodotti Finiti (Final Products) as objects of performance measurement of prevention services was born at a local level in 1998; then, in 2006, it was spread to all LHAs by the regional level in order to have a uniform and shared system. The players involved in this initiative have been the local and regional levels as the promoter of the introduction of the Prodotti Finiti system and the groups of professionals as the decision-makers of what products and what elements should have to be measured. In the experience of the design of this system the professionals seem to have been the strongest decisional level: they have decided what were the objects to be measured. The political levels (regionals and local) could choose to limit the analysis to some products (as key performance areas) or to some particular elements of the products but these were second hand choices because strictly linked to the assumptions and the decisions already made by professionals. Although the choice of involving professionals in the design of the measurement system is fundamental for the consensus, it could lead to a limited power of the other decision makers, so confirming the strenght of professionals’ power in designing performance measurement systems in health care organizations.