PERFORMANCE MANAGEMENT POLICIES PERFORMANCE MANAGEMENT POLICIES OF HEALTH SYSTEMS IN OF HEALTH SYSTEMS IN

TURKEY AND ENGLAND: TURKEY AND ENGLAND:

A CRITICAL COMPARATIVE REVIEWA CRITICAL COMPARATIVE REVIEW

Dr. Pinar Guven-UsluNorwich Business School, University of East Anglia, UK

p.guven@uea.ac.uk

Dr. Gulbiye Yenimahalleli YasarAssist. Professor, University of Ankara, Turkey

gulbiyey@yahoo.com 

 

Aim of the paper

To investigate recent policy changes around performance management in the Turkish health care system and comparisons with English health service management.

Performance management related Performance management related changes in Turkish health care changes in Turkish health care systemsystem

Turkey used to run a nationalised health system during the five decades.

It was faced with serious problems;due to the lack of interest of the health

authorities

Thus, Turkish health system entered to the eighties with various problems (Aksakoglu, 2011; Yavuz, 2011).

Turkish health care system has been experiencing neo-liberal transformation since the coup d’état in 1980.

Reform proposals of the 1990s focused on◦ the introduction of a general health insurance (GHI)

system, ◦ decentralisation, ◦ introduction of a family medicine scheme, ◦ purchaser-provider split, ◦ contracting out, ◦ quasi-markets, ◦ improvement of management information systems (MoH,

1993).

Subsequent attempts have been made by “Health Transformation Program” (HTP) since 2003.

The HTP aims to achieve a transformation in the framework of eleven themes:

1. MoH as planner and supervisor, 2.General Health Insurance (a single fund),3. Widespread, easily accessible and friendly health system,

a) Strengthened primary health care services,b) Effective and graduated chain of referral,c) Administratively and financially autonomous health enterprises,

4. Knowledge and skills-equipped and highly-motivated health service personnel,

5. System-supporting educational and scientific bodies,6. Quality and accreditation for qualified and effective health care

services,7. Institutional structuring in rational drug use and material

management,a) National Pharmaceuticals Agency,b) Medical Devices Agency,

8. Access to effective information in decision-making: Health Information System

9. Health promotion for a better future and healthy life programmes,10. Multi-dimensional health responsibility for mobilizing parties and

inter-sectoral collaboration,11. Cross-border health services to increase the country’s power in

the international arena (Akdag, 2009).

For ‘knowledge and skills-equipped and highly-motivated health service personnel’, a performance-based supplementary payment (PBSP) system was introduced in MoH hospitals in 2004.

In 2008 there were 1.350 hospitals; ◦847 of which MoH hospitals, ◦57 of which university hospitals, ◦400 of which private hospitals and ◦46 of which other hospitals in Turkey

Reforming MoH hospitals in Turkey Reforming MoH hospitals in Turkey

HTP aims to create “administratively and financially autonomous health enterprises”

All public facilities have been integrated under the MoH in 2005

A pilot hospital autonomy law was drafted in 2007 setting out the principles of hospital governance

The law offers the possibility of the creation of a joint hospital union at the regional level.

The MoH would be responsible for guaranteeing quality of care and adherence to MoH standards in hospital unions (Yenimahalleli Yasar, 2011).

The implementation of hospital autonomy has not been accomplished yet.

hospital reforms carried out to date; (i) granting hospital managers more

autonomy and flexibility over the management of revolving funds,

(ii) implementation of a PBSP system; (iii) outsourcing of hospital clinical

diagnostic services to the private sector; (iv) upgrading health information systems(v) implementing hospital quality and

efficiency audits (OECD-WB, 2008).

Objectives of the PBSP system in TurkeyObjectives of the PBSP system in Turkey

The PBSP system has aimed to encourage job motivation and productivity among public sector health personnel claiming shortage of both physicians and nurses.

◦ the ratio of health personnel to population was lower than in other middle-income and OECD countries,

◦ the majority of public doctors worked part-time and ◦ doctors preferred to work in the private sector.

Another important objective is to improve performance of the MoH hospitals, focusing on quality of care, efficiency and patient satisfaction (MoH, 2008:45; OECD-WB, 2008:49).

Historical development of the PBSP Historical development of the PBSP system in Turkeysystem in Turkey

The PBSP system in Turkey can be examined under three phases:

(a) Before 2004

(b) PBSP system in 2004(c) Quality Improvement and Performance Evaluation System from 2005 onwards.

(a) (a) Before 2004:Before 2004:

The staff working in the institutions with revolving budgets started to get payment from the revenues of revolving budgets since 1990

The major features of the system before 2004 are:

a. Outsourced staff working in the services such as cleaning, security, data entry into computers and catering do not benefit from supplementary payment.

b. Top supplementary payment rate is applied as 100-120% for doctors, and 80% for other staff.

(b) PBSP system in 2004:

In 2004 the system was piloted

Initially pilot has been realized for ten hospitals

Subsequently expanded to the all MoH facilities

Developed by strictly monitoring the changes and evaluating the feed backs

Currently all 850 MoH hospitals have in place within the PBSP system

(c) Quality Improvement and Performance Evaluation System from 2005 onwards:

Introduced some elements of “internal markets” whereby the MoH Performance Management and Quality Improvement Unit implements a pay-for-performance scheme in MoH hospitals, linked to institutional performance criteria.

20032003

20042004

20052005

20062006

20082008

PPIILOT LOT STUDYSTUDY

Development and implementation of the modelDevelopment and implementation of the model

INDIVIDUALINDIVIDUAL

MANMANAAGERGERIALIAL

INSTITUTIONALINSTITUTIONAL

CLINIC INDICATOR CLINIC INDICATOR SPECIFICATIONSPECIFICATION

What is the PBSP system?What is the PBSP system?

An additional payment in addition to regular salaries.

Base salary from line item budget.

Performance-based payment from hospital earnings

Bonus payments linked to performance of health personnel.

Payment to health personnelPayment to health personnel

Each personnel earns a fixed salary

+ A bonus

related to their own performance and the performance of the hospital

Line-item

budgetHospital

Revenues

Salary + PBSP

Fixed

Individual performance

Institutional performance

Individual performance Individual performance measurementmeasurement

Each service is rated with a point

Each clinician collects points from his/her tasks (load of service)

2005 HASTANE

KO DU

BUT 2005

KO DUİŞLEM ADI PUANI

510.121Dahili branşlardaki servislerde günde en az iki kez yapılan hasta başı vizit (günlük her hasta için)

21

520.010 Konsültasyon ücretleri (her bir hekim için) 10520.020 Acil poliklinik muayene ücreti 21520.030 Normal poliklinik muayene ücretleri 21

520.031 Sevki yapılan muayene 5520.032 İçapcı nöbetinde yapılan muayene 30

520.033Psikiyatri Muayenesi (ilk 10 hasta için 30 puan sonraki hastalar 21 puan)

30

530.020 Apse veya hematom drenajı, derin 150530.100 Elektrokardiyogram 0530.140 IM enjeksiyon 0530.150 IV enjeksiyon 0

530.581 Ria takılması 40550.130 Anestezi A1 grubu (Özellikli ameliyatlar ve girişimler) 1.200

550.131Anestezi A1 grubu (Özellikli ameliyatlar ve girişimler),uzman ve anestezi teknisyeni birlikte

400

604.660 Valvotomi, mitral kapak, kapalı 1.280

604.910Koroner arter by-pass, karotid endarterektomi + patch plasti

2.500

607.980 Splenektomi, total 500610.130 Appendektomi 420619.910 Müdahaleli doğum 143619.920 Normal doğum 143

619.921 Ebe eşliğinde yapılan doğum 36619.930 Sezeryan 143801.690 Akciğer grafisi (iki yön) 4804.190 MR, beyin 20901.500 Glukoz 0

All procedures made by the mentioned units are billed and priced according to tariff (SUT)

How does it work?How does it work?

Factors which determine how much health personnel will receive as performance-based payments:

◦ The total amount capped at 40% of hospital revenues.

◦ This total (capped) amount is subsequently adjusted based on institutional performance of the hospital (0-1).

◦ An individual level performance score is calculated for each staff member.

◦ Total points score for a physician is adjusted by a job title coefficient

Distribution of Hospital RevenuesDistribution of Hospital Revenues

Hospital Revenues

15 % Treasury Share

0 – 40 %

PBSP Budget

45 – 85 %

Regular Hospital

Expenditures

Management Board

the total amount that health facilities can allocate to performance-based payments to health personnel is capped at 40% of revenues

40 %

capped amount

0.8

institutional performance adjustment*

> 40% of hospital revenue

0 - 1

x=

32 %

devoted to staff bonuses

Effect of institutional performance on the amount to be transferred to the staff

Healthcare institution’s revenues

Individual performance Individual performance measurementmeasurement

Each service was rated with a score

Each clinician collects scores from his/her tasks (load of service)

Individual scores and Hospital average

100021

300

1030 1000

21

300

1030

10 21

300

1030

21 2121

21300

13.000 7.00015.000 5.000 17.000 ++++

Dr 1 Dr 2 Dr 3 Dr 4 Dr 5

57.000 /5

11.400

Σx1...xn /n

Indirect performance score estimationfor those who do not have scores of medical procedures

xBIOCHEM. SPEC.

xAUX.

xCIV. SER.

xNURSE

xANES.TEC

xMANAGER

=2.5x

=.25x

=.25x

=.4x

=.5x

=1x

OTHER

xHEAD PHYSICIAN =4.5x

AdjustmentsAdjustments

The total points score for a physician is adjusted by,

◦ a job title coefficient: to measure workload aside from providing clinical care (i.e. administrative duties, teaching etc.)

◦ the number of days the person has worked in that month.

◦ depending on whether the person is doing private practice or not (0.4/1.0).

Institutional Performance ComponentInstitutional Performance Component

40 %

capped amount

0.8

institutional performance adjustment*

> 40% of hospital revenue

0 - 1

x=

32 %

devoted to staff bonuses

categories categories of indicators for institutional of indicators for institutional performanceperformance

Institutional Performance

0 - 1

Access to examination

Infrastructure and process

Patient satisfaction

Institutional productivity

Institutional targets

N1 + N2 + N3 + N4 ∑: N1 -N4 / 4

Types of upper cap restrictions in the system:

◦Cap for distributing hospital revenues (40 %)

◦Control of fluid cash (Managerial Board)

◦Multiplier of basic salary for profession

Upper Cap Restrictions

CCaps for bonuses as multiplier of aps for bonuses as multiplier of basic salarybasic salary

   CoefficientCoefficient

Full timeFull time clinic chiefs and associate chiefs clinic chiefs and associate chiefs 88

Full time Full time specialist physicians, specialist dentistsspecialist physicians, specialist dentists 77

Ful time Ful time practitioners and dentistspractitioners and dentists 55

CClinic chief, associate chiefs, specialist physicians, specialist dentistslinic chief, associate chiefs, specialist physicians, specialist dentists doing private practice (part time)doing private practice (part time) 3,53,5

PPractitioners and dentists ractitioners and dentists doing private practice (part time) doing private practice (part time) and and hospital managers and pharmacistshospital managers and pharmacists 2,52,5

Head nurses and the Head nurses and the staffstaff working in specific services such as ICU working in specific services such as ICU (Intensive Care Unit)(Intensive Care Unit), delivery, newborn, nursing infant, burn, , delivery, newborn, nursing infant, burn, dialysis, surgery, bone marrow transplantation unit, ER, mental dialysis, surgery, bone marrow transplantation unit, ER, mental health and the psychiatry services in the hospitalshealth and the psychiatry services in the hospitals 22

The other The other staffstaff 1,51,5

Individual bonuses for staff are capped at a certain multiplier of basic salary.

Differences in other settingsDifferences in other settings

PHC facilities

Some preventive healthcare service indicators are used for scoring.

Adjustments are made according to the characteristics of the region where the personnel is working.

Training Hospitals Additional scores are given for;

◦ Training activities and ◦ Scientific publications

Consequences of PBSP System in TurkeyImpact on utilisation of resourcesThe general efficiency of hospital has been

increased after the PBSP system in Turkey. ◦ the increase in total revenue of the hospital, and per

day, ◦ in consultation per doctor, ◦ in the number of hospitalization per doctor and ◦ in the ration of capacity utilization has been seen

However, PBSP system leads to unnecessary resource utilization◦ increase in the length of stay in the hospital, ◦ unnecessary tests per patient, ◦ number of procedure, ◦ increase in the expenditure of the treatment (Tengilimoglu,

Pay, and Kisa, 2008).

Impact on satisfaction and motivation of health personnel

The level of motivation of health system after the PBSP system is still low. The main problems:the deduction of the additional payment while on leave, the existence of big differences between the professions, the perception of uncertainty concerning the future of

the additional payment (MoH, 2010: 43).

There are negative reactions to the PBSP system;Creating competition among health professionals and a

resulting erosion of teamwork. Medical education is affected negatively since university

hospitals became reluctant to admit complex patients Academic staff began to work at outpatient clinics in

order to gain greater bonus payments. The PBSP system also encourages partisan behaviour

(TMA, 2007).

There are some significant differences among personnel’s review about PBSP system in terms of gender, education status, vocations and departments.

The health personnel found this system is unjust because of both the imbalance of fee rates between the doctors themselves and doctors with other personnel (Gazi et al, 2009).

Impact on health services According to a research which investigates the effects of the PBSP

system on primary health care in Bursa shows that there had been some differences in health care quantities before and after the PBSP system.

As an example; while examination and laboratory study numbers had increased, the ratio of referring had decreased.

Besides, infant mortality rates had decreased, risk groups’ mean follow up rates had increased.

In general, these differences have to be seen positive in terms of health care.

But, because of the structure of the system, to have a judgement about the quality of the care is impossible.

The study concludes that if care has been evaluated not only in terms of quantity but also quality, beyond the desired, there had been some unfavourable returns of the system. For that reason leaving the system or to restructure is thought to be appropriate (Kizek et al, 2010).

Performance Management Changes in English National Health Service

Since the publication of ‘The New NHS: Modern and Dependable’ white paper (DoH, 1997), the UK’s National Health Service (NHS) has undergone considerable structural reorganisation.

This was a ten year programme that aimed to provide ‘the best healthcare in the world’ (DoH, 1998).

Cost and service quality improvements were expected to be achieved through greater collaboration and partnership, benchmarking and the implementation of performance related management.

The annual publication of ‘league tables of hospital efficiency’, however, allowed direct cross-organisation comparison on the basis of cost alone and this, therefore, was inclined to shift priorities towards cost of care at the expense of quality of care (Jones, 2002).

In order to address some of these critics, the Government then introduced the ‘star rating’ system to measure organisational performance of hopsitals with first wave implementaiton in 2002-03.

This was a multi-dimensional measure combining financial and non-financial performance measures that are defined by the DoH.

It was an adoptation of a balanced score card approach (Kaplan and Norton, 2001) with an expectation to combine financial outcomes such as balanced budget, with patient satisfaction outcomes such as 4 hours waiting times to be seen at an Accident and Emergency Unit, or hospital cleanliness etc.

Each defined area of performance had a centrally determined target to be achieved by hospitals.

The NHS performance ratings system placed NHS hospitals in England into one of four categories:

trusts with the highest levels of performance are awarded a performance rating of three stars

trusts that are performing well overall, but have not quite reached the same consistently high standards, are awarded a performance rating of two stars

trusts where there is some cause for concern regarding particular areas of performance are awarded a performance rating of one star

trusts that have shown the poorest levels of performance against the indicators or little progress in implementing clinical governance are awarded a performance rating of zero stars

Where a trust has a low rating based on poor performance on a number of key targets and indicators, it meant that performance must be improved in a number of key areas.

The Government's purpose in introducing star ratings was ◦ to lessen variation in performance between trusts, ◦ raise standards, and ◦ make services more accountable to the public.

The system was abolished in 2004 and was replaced by a new system of annual health checks.

Some of the main performance indicators remained but the philosophy behind centrally rating of performance, ranking of organisations according to that calculation and publication of these rankings in public domain started to change.

The Healthcare Commission replaced the Commission for Healthcare Improvement in March 2004 and introduced the annual health check with a belief that "health checks" can be used to provide an annual report on each health care organisation.

This was a self declaration by hospitals on their organisational performance.

A number of trusts randomly selected would be audited to assess whether they had made a fair declaration of their organisational affairs.

Around the same time in 2004, the Foundation Trust concept was introduced to the NHS to devolve decision making from central to local organisations and communities.

It represents a profound change in the history of the NHS and the way in which hospital services are managed and provided. FTs have been assessed as performing as expected by the Government according to targets set for them.

Some of the requirements to become a foundation trust were; ◦ balanced budget (no deficit), ◦ have and operate a performance management framework, ◦ meet national clinical targets such as A&E waiting time of 4

hours.

They have the freedom to use their surplus in their preferred ways. They are regulated by an independent body Monitor.

From 2006, an annual health check replaced the 'star ratings' assessment system and looked at a much broader range of issues than the targets used previously.

It sought to make much better use of the data, judgements and expertise of others to focus on measuring what matters to people who use and provide healthcare services.

Trusts had to declare their compliance with the core standards set out in Standards for Better Health[9][10], published by the Department of Health in 2004.

The Standards for Better Health (SfBH) document sets out the level of quality that all NHS organisations are expected to meet or aspire to in the delivery of care.

The document contains 24 standards with 44 elements that healthcare organisations are annually assessed against. From April 1st 2009 the responsibility for regulating SfBH has moved to the Care Quality Commission.

The standards have been developed with two principle objectives; ◦ first, they provide a common set of requirements applying

across all health care organisations to ensure that healthcare is commissioned and provided safely and are of a high quality;

◦ second, they provide a framework for continuous improvement in the overall quality of care that people receive.

The standards set out in SfBH are organised within seven "domains", which are designed to cover the full range of health care as defined in the Health and Social Care (Community Health and Standards) Act 2003.

The domains cover all areas of health care, including prevention, and are described and monitored in terms of outcomes.

The seven domains are:- Safety Clinical and Cost Effectiveness Governance Patient Focus Accessible and Responsive Care Care Environment and Amenities Public Health

From April 2010 all healthcare providers working for the NHS will be legally obliged to publish "quality accounts" on safety, patients’ experience, and clinical outcomes, in the same way that they publish financial accounts.

The accounts will augment the government’s agenda on choice by giving patients information - accessible through NHS websites - on all health services in England, to help them decide where to be treated.

Legislation will dictate that all providers produce their first quality account - carrying a pre-selected set of measures for public consumption - at the end of 2009-10.

This means deciding which measures will be included, and making sure solid data collection is in place to report them, before the end of March 2010.

ComparisonWith a contextualist approach to this analysis,

we conclude that each country’s healthcare system is in important ways unique and highly local: ◦ a product of its distinctive history, ◦ its particular politics, ◦ its economic system, ◦ its geographical and cultural diversity, and ◦ its values.

We grouped our analysis according to three dimensions of contextual approach to change management.

HTP - NHS - ComparisonNeo liberal transformation since 1980’s

HTP Programme announced by JDP 2003 based on 11 themes

Central objective:‘High quality and effective health system accessible to all’

Performance based supplementary payment (PBSP) 2004

Health Information System (2007)

Autonomous hospitals (2008)

Cross border health services (2009)

‘New NHS’ White Paper (DoH, 1997)

Central objective: To achieve best healthcare in the world

Reference Costs (1999)

Payment by Results (PbR) (2002)

Star rating system (2002-3)

Patient Choice (2004)

Foundation Trusts (2004)

Annual health checks (2004)

Two regulators: Care Quality Commission and Monitor

Similarities: Influence of NPM: liberalisation in terms of market management, performance management and monitoring

Ambitious change programmes implemented by strong political power

Aim: to Increase quality with better control of resources

Attempt to measure performance and reward (but the way of assessment and type of reward are different)

Differences: Calculation of organisational performance achievement and differences in majority of metrics

Therefore fund allocation principles are fundamentally different

No regulatory institution in for health services: performance management, monitoring, pricing of services all under control of Government

Comparison of outer context

HTP - NHS - Comparison

Private sector provision: inequality of pay and access

Non transparency in fund allocation

Emerging conflicts between and within clinical and managerial professionals

Continuous change in measuring organisational performance since 1997

Financial metrics vs quality metrics and continuous attempts to reach a good balance

Continuous pressure to meet targets:Managerial- Clinical conflicts

Similarities:Some level of conflict and discomfort –internal management and professional conflicts

Continuous measurement and reporting

Autonomous hospitals and Foundation Trusts

Differences:Individual performance monitoring in Differences in organisational culture in hospital management (clinical professionals in management posts in )

Comparison of Inner Context

HTP - NHS - Comparison

Content Content

Top down, centrally governed, managing the demand side

Top down but requires bottom up action, managing demand and supply side with an attempt to control and regulate the market (entries exists and pricing as well as performance monitoring and control)

Similarities:Overall aim of increasing quality and better resource managementDifferences:Consultation with professionals in Expert studies and reports in Private sector provision in

Process Process

Revolutionary, ‘Big Bang’ appraoch Long term plan with milestonesContinuous change and evolution

Similarities:Organisational reporting Increased information managementDifferences:Timeline – not clear in Turkish system

Comparison of Content and Process

Thank you very much