Abstract Book - EHMA

HOSTED BY
EHMA Annual Conference 2012
Public healthcare:
who pays, who provides?
13-15 June 2012
Kursaal Bern - Bern, Switzerland
ABSTRACT BOOK

Wednesday 13 June 2012
Table of Contents
Special interest group: Primary Care .................................................................................................................................. 13
Developing Clinical Governance Innovative practices in Primary-care: Self-organization and vertical integration
Dynamics, Luis Velez Lapão, Claudia Leone 14
Assessing the economic impact of Disease Management programs to prevent cardiovascular diseases in Italy: the
Raffaello Program, Matteo Ruggeri, Americo Cicchetti, Alberto Deales WITHDRAWN
Working as a locum GP: their professional role in organizational context, Ronald Batenburg, Daniel van Hassel,
Lud van der Velden 16
Clinical Vignettes: a Time-Driven Activity Based Method for Measuring Micro-Costs in Primary Care in Europe
16
Antonio Sarría, Giovanni Fattore, Virginia Del Pino, Almudena Albertos, Eleonora Corsalini
A proposal to define a framework to classification models of primary care in Europe, Antonio Sarría,
Virginia del Pino, Almudena Albertos 18
Special interest group: Healthcare Workforce Management .................................................................... 19
Achievement of patient safety through quality occupational health management in Bulgaria, Nevena Tzacheva,
Jasmine Pavlova, Vasil Pisev, Lydia Christova 20
Patient Safety in Primary Care in Albania, Adriatik Gabrani, Jonila Gabrani, Eliziana Petrela 21
Nurses and burn-out at Work place, Zarema Obradovid, Ifeta Skoro, Amina Obradovid 22
Clinicians on Board: What Difference Does It Make To Hospital Performance? Gianluca Veronisi, Ian Kirkpatrick
(presented by Kathy Hartley) 23
Thursday 14 June 2012
Parallel Session: Primary Care and Financial Incentives ............................................................................ 24
Economic Incentive – one Way of Promoting Patients’ Health Gain In The Health Care System, Anna Friberg 25
Shared savings between payers and providers of health care: preliminary findings from a case study in the
Netherlands, Arthur Hayen, Michael van den Berg, Bert Meijboom, Gert Westert 26
Integrated or not integrated? What future for PCGs? Francesca Scolari, Emanuela Foglia, Emanuele Porazzi,
Umberto Restelli, Daniela Malnis, Giovanni Beghi, Antonino Mazzone, Carla Dotti 27
Provider strategies in the downturn: the power of economic incentives to primary care resolution improvement,
Tino Martí, Antoni Peris, Alba Brugués 28
Parallel Session: Evidence Based Planning................................................................................................ 29
Research Inventory of Child Health in Europe (RICHE) - An EU Project for Systematic Collection and Presentation of
Evidence, Michael Rigby, Denise Alexander 30
Management capacity of Greek hospitals - a case study in the development of strategic management plans,
Elisabeth Kounougeri Petsetaki, Cornilia Vasiliadou 31
Prediction of unplanned readmission among hospitalized patients in Stockholm county council: a population based
cohort study, Gustaf Edgren, Michael Högberg, Patrik Stäck, Birger Forsberg, Joachim Werr 32
2

Planning for Future Health Care in Stockholm, Birger Forsberg, Kajsa Westling, Håkan Lenhoff, Yvonne Lettermark 34
Parallel Session: Health Workforce: New World – New Roles? .................................................................. 35
Employing Nurses In Advanced Roles in Portugal: Evidence, Enablers and Barriers to Innovation, Gilles Dussault,
Inês Fronteira, Marta Temido, Luis Lapão, James Buchan 36
Exploring the potential of e-Health in the provision of integrated pharmaceutical care services, João Gregório,
Luís Lapão 37
Performance analysis within clinical directorates: evidences from Italian NHS, Americo Cicchetti, Daniele Mascia,
Federica Morandi, Ilaria Piconi 38
Parallel Session: Patients’ Perspective ..................................................................................................... 39
Informal health care payments in Romania in the context of health system reform, Marius Ionut Ungureanu,
Razvan Mircea Chereches, Ioana Andreea Rus, Cristian Marius Litan, Bianca Baciu 40
Long term healthcare reform effects in health professionals and patients' knowledge and attitudes. A social
anthropology perspective, Laia Bailo, Tino Martí, Antoni Peris, Alba Brugués 41
Producing and funding future elderly care services - different generations' perspectives, Minna Kaarakainen,
Virva Hyttinen, Sanna Suomalainen, Sampsa Wulff 42
The Integration of Patients in the Services Processes Attitudes of the Upper Austrian Population, Margit Raich,
Daniela Deufert, Christoph Zulehner 43
Thematic Parallel Session: Integration ..................................................................................................... 44
Increasing Integration of Healthcare Services Through New organisational Forms: Networks For Multi-Chronic
Patients, Federica Segato, Martina Dal Molin, Cristina Masella 45
Shedding a network light on integrated care -A different (re)view on performance of dementia care networks,
Iris Saliterer, Sanja Korac 46
Trends of models in hospital governance in the Netherlands: failing integration of medical specialists in hospitals?
Linda Muijsers 47
Developing Clinical Governance Innovative practices in Primary-care: Self-organization and vertical integration
Dynamics, Luis Velez Lapão, Claudia Leone 49
Thematic Parallel Session: Working Together ........................................................................................... 50
Hospital boards and medical specialists collaborating for quality of care, Daan Botje, Thomas Plochg, Niek Klazinga,
Cordula Wagner 51
INFESTO - Anti Infection Policy, Juhani Pekkola 52
Different Work Values and Aims of Subcultures - Impacts on Patient Care, Margit Raich 53
Understanding Board Governance and Patient Safety: a Programme Theory Perspective, Ross Millar, Tim Freeman,
Russell Mannion 54
Thematic Parallel Session: Operations Management ................................................................................ 55
Health Care Redesign: Managing a Changing Health Care Environment, Melissa De Regge, Paul Gemmel,
Rik Verhaeghe, Bart Sijnave, Peter Degadt, Philippe Duyck 56
Processes' mapping in health centers, Silvina Santana, Patrícia Redondo 57
3

Quality of Service and Quality of Consumables and Medical Devices: who pays and how the De- Centralized vs
Centralized procurement process can support Patient Safety? Anastasia Balasopoulou, Christos Mpoursanidis 58
Operational access to long-term care for elderly: findings from a case study in the Netherlands, Lisette Schipper,
Bert Meijboom, Katrien Luijkx, Jos Schols 59
Selection and Weighting of Performance Indicators in a Private Healthcare Organization: The Balanced Scorecard as
a tool to support management, Lara Santos, Denise Santos 60
The Application of Logical Framework Technique as Quality Management Tool across Diverse Settings in a Tertiary
Care Hospital In Malta, Sandra C. Buttigieg, Prasanta Dey 61
Friday 15 June 2012
PhD Students’ Session ............................................................................................................................. 62
Strategizing in a Messy Context. A Study of Academic Medical Centers, Adriana Allocato 63
Public healthcare organizations: Who really drives the change? Ekaterini Fameli, Erik Soderquist 64
Developing Integrated Care. Towards a Development Model For Integrated Care, Mirella Minkman 65
Framing and re-framing calamities in hospitals: how different views on calamities shift responsibilities from
professionals towards managers, Lonneke Behr, Kor Grit, Roland Bal, Paul Robben 66
Directive on the Application of Patients’ rights in Cross-Border Healthcare: Outcomes of a Simulation ..... 67
EU Cross-Border Health Care Survey 2010 - Patient Satisfaction, Quality, Information and Potential,
Caroline Wagner, Katharina Dobrick, Frank Verheyen 68
Parallel Sessions: Sustainable Financing ................................................................................................... 69
How to get maximum reimbursement, Anne-Marie Yazbeck, Primož Lukšič, Alen Orbanid, Jernej Bodlaj,
Katja Grašič 70
Use of patient level costing data to establish value-based public healthcare in England, Mahmood Adil,
Naomi Chambers 71
Possibilities for Sustainable Financing of the Estonian Social Insurance System, Ain Aaviksoo, Priit Kruus,
Lauri Leppik, Riina Sikkut, Vootele Veldre, Andres Võrk 73
Parallel Sessions: New Providers, New Models of Care ............................................................................. 74
Pluralism in healthcare commissioning: patterns of destablisation in the English NHS, Rod Sheaff, Nigel Charles,
Naomi Chambers, Ann Mahon, Sue LLewellyn, Russell Mannion, Mark Exworthy, Richard Byng 75
Public-private-partnerships in health promotion: experiences, opportunities and readiness in Switzerland,
Michael Kirschner 77
Non-profit Providers in Stockholm County Council – Obstacles to Entering the Healthcare Market,
Kajsa Westling, Ida Nyström, Birger Forsberg 78
Can health care system be able to personalise its Service? Mathias Waelli, Etienne Minvielle 79
Parallel Sessions: Involving Citizens ......................................................................................................... 81
Engaging Patients in the Commissioning of Chronic Pain Services: A Model for Effective Patient and Public
Involvement, Elaine McNichol 82
4

A paradigm shift in governance of local care and social service in the Netherlands: from central provision to local
participation, Kim Putters, Maarten Janssen 84
Bring a Friend - A Peer Education Program For Cervical Cancer Screening among Immigrants,
Malena Lau, Erik Olsson, Mia Westlund, Eva Runå-Ljungberg, Bodil Frey 85
Poster Sessions ....................................................................................................................................... 86
CEOs' career patterns in healthcare: evidences from the Italian National Health Service,
Daniele Mascia, Ilaria Piconi, Americo Cicchetti 87
Investigating the organizational impact of the introduction of new oral anticoagulant therapies (OATs),
Americo Cicchetti, Federico Spandonaro, Vincenzo Aparo, Matteo Ruggeri, Maria Letizia Mancusi, Silvia Coretti,
Paola Codella 88
Conceptual framework for organizational model assessment of Hospital Centers (HC), Ana Simões,
Américo Azevedo, Suzete Gonçalves 89
Comprehensive Value Estimation of Adalimumab-Based Treatments: Covet Study, Andrea Marcellusi, Lara Gitto,
Patrizia Giannantoni, Francesco Saverio Mennini 90
Social impact of Adalimumab in the Italian perspective, Andrea Marcellusi, Lara Gitto, Patrizia Giannantoni,
Francesco Saverio Mennini 91
Research on the Need for “Medical Home Patronage” Services in Bulgaria, Antoniya Yanakieva 92
Conceptualizing and measuring performance in the domain of nursing care: a systems approach,
Carl-Ardy Dubois, Danielle D'Amour, Marie-Pascale Pomey, Francine Girard, Isabelle Brault 93
How does prenatal care affect the birth mode? Christine Vietor, Julia Weller, Andrea Gillessen,
Anita Kettelgerdes, Torsten L Hecke 94
Improving health care in women with uterine fibroids by using an integrated care model,
Claudia Junkmanns, Peter Dueker, Susanne Klein (presented by Christine Vietor) 95
The Use of Root Cause Analysis for Error Detection In Histology - Impact on Quality and Safety of Patients,
Umberto Restelli, Emanuele Porazzi, Pamela Morelli, Emanuela Foglia, Marzia Bonfanti, Michela Ruspini,
Giuseppe Banfi 96
Patient participation through patient-centered eHealth applications: A utopia? Femke Vennik, Samantha Adams,
Kim Putters 97
Hospice care in Bulgaria - who pays, who provides? Silviya Aleksandrova-Yankulovska, Gena Grancharova,
Toni Vekov 98
Outsourcing In Turkish Hospitals: A Systematic Review, Yasemin Akbulut, Gözde Terekli, Turkan Yildirim 99
New proposed schemes for chronic patient management in Regione Lombardia."Chronic related Groups (CReG)"
under testing in five Local Health Authorities AND the experience of "Primary Care Groups" PCG) in the Pavia Local
Health Authority, (Lombardy, Italy), for care delivery to chronic patients,
Guido Fontana, Simonetta Nieri, Carlo Cerra, Sergio Pellegrino, Roberto Nardi 100
Medical Service Centres – Fixed Income versus Individual Income within Cooperations of SHI-doctors,
Josef Farnschläder, Harald Stummer 101
Path Management in multimodal pain management – Impact on quality and costs? Evidence from Germany,
Tobias Romeyke, Harald Stummer 102
Managed Care - a Pilot Projekt of Stroke Management in Austria, Klaus Buttinger, Harald Stummer 103
Raising funds for the National Health System: Physician’s perspective, Helena Pereira, Denise Santos 104
Approaches for optimizing the financial hospital management and quality of services (through experience in
Bulgaria), Jasmine Pavlova, Vasil Pisev, Nevena Tzacheva, Lora Afanasieva, Ivaylo Ivanov 105
5

Developing National Quality Measures for Infants and Toddlers Preventive Health Services as a Tool for Decision
Making, Keren Dopelt, Nadav Davidovitch, Itamar Grotto 106
Attitudes of pharmacists and physicians to antibiotic use and microbial resistances - a pilot study,
Fátima Roque, Clarinda Neves, Sara Soares, Mónica Ferreira, Luiza Breitenfeld, Odete Cruz e Silva, Adolfo Figueiras,
Maria Teresa Herdeiro 107
Educational Interventions to improve antibiotic use and to reduce costs associated with inappropriate consumption
Fátima Roque, Sara Soares, Luiza Breitenfeld, Odete Cruz e Silva, Adolfo Figueiras, Maria Teresa Herdeiro 108
Influence of the self-efficacy on the health behaviour among vocational educated youth and young adults,
Marja-Leena Kauronen 109
Assessing the costs of the health pathways: the case of DIABETES in an Italian healthcare district,
Americo Cicchetti, Matteo Ruggeri, Daniela Bianco, Silvia Colombo, Emiliano Briante, Paola Codella,
Angelica Carletto Error! Bookma
Routine assessment of effectiveness of secondary health care in the Helsinki University Hospital,
Pirjo Räsänen, Marja Blom, Olli-Pekka Ryynänen, Harri Sintonen, Risto P. Roine 111
Alzheimer’s Disease - Resource Providing and Economics for Ensuring Care of Patients in Palliative Medicine,
Ranko Stevanovic, Lovorka Bilajac, Ivan Pristas, Irena Rojnic Palavra, Vanesa Benkovic 112
IEMAC: a tool for guiding healthcare organizations in their answer to chronicity, Roberto Nuño, Nuria Toro,
Paloma Fernández-Cano, Jose Joaquin Mira, Olga Solas, Joan Carlos Contel 113
Foreign trained dentist working in the Netherlands: motives and movements in cross-border behaviour,
Ronald Batenburg, Inge van der Lee, Phil Heiligers 114
Evaluation of Tyrolean hospitals to obtain the accreditation "Selbsthilfefreundliches Krankenhaus" (Support Group
Friendly Hospital), Vladan Antonovic (presented by Siegfried Walch) 115
Accessibility of Primary Health Care Services in Urban Community of Lithuania, Skirmante Sauliune,
Mindaugas Stankunas, Ramune Kalediene 116
Public-private cooperation in oral health care in Finland, Anne Nordblad, Elina Tuppurainen, Pirkko Paavola,
Sari Mäki, Taina Mäntyranta 117
The network structure of nanomedicine: exploring the role of health care providers, Americo Cicchetti,
Valentina Iacopino, Daniele Mascia 118
The performance evaluation of policy networks in the integrated care: connecting theories to organizational praxis.
An experimental case study developed in a Spinal Unit of Lombardia Region to evaluate the performance of policy
networks managing the pathway of persons with Spinal Cord Injury, Verdiana Morando 119
Integrated health care - Austria on its way, Victoria Höß, Verena Stühlinger, Harald Stummer 121
Seniors' willingness to participate in working life after retirement, Minna Kaarakainen, Virva Hyttinen,
Sanna Suomalainen, Sampsa Wulff, Markku Hänninen 122
Comprehensive assessment of patient safety in medical organizations of the Republic of Kazakhstan, Vitaliy Koikov,
Gulmira Derbissalina 123
Practice Example: Status Quo of Back-Pain Patient's Cross-Sectoral Path of Medical Treatment In Germany,
Wilfried von Eiff, Alexandra Groth, Samir Al-Hami, Stefan Schüring 124
Burden of MRSA - Quality, Costs and Risks In Patient Care, Wilfried von Eiff, Dennis Haking 125
Impact of Health Insurance Institute financing policy in financial and performance outcome of health
centres, Gazment Koduzi 125
Health Management of chronic occupational diseases - a challenge for Bulgarian economy and Public Health, Karolina
Lyubomirova, Nevena Tzacheva, Milena Yancheva, Lidia Hristova 126
126
126
6

Authors
Aaviksoo, A. 72
Adams, S. 96
Adil, M. 70
Afanasieva, L. 104
Akbulut, Y. 98
Albertos, A. 16, 17
Aleksandrova-Yankulovska, S. 97
Alexander, D. 29
Al-Hami, S. 123
Allocato, A. 62
Antonovic, V. 114
Aparo, V. 87
Azevedo, A. 88
Baciu, B. 39
Bailo, L. 40
Bal, R. 65
Balasopoulou, A. 57
Banfi, G. 95
Batenburg, R.15, 113
Beghi, G. 26
Behr, L.65
Benkovic, V. 111
Bianco, D. 109
Bilajac, L. 111
Blom, M. 110
Bodlaj, J. 69
Bonfanti, M. 95
Botje, D. 50
Brault, I. 92
Breitenfeld, L. 106
8
Breitenfeld, L. 107
Briante, E. 109
Brugués, A. 27, 40
Buchan, J. 35
Buttigieg, S. C. 60
Buttinger, K. 102
Byng, R. 74
Carletto, A. 109
Cerra, C. 99
Chambers, N. 70, 74
Charles, N. 74
Christova, L. 19
Cicchetti, A. 14, 37, 86, 87, 109, 117
Codella, P. 87, 109
Colombo, S. 109
Contel, J. C. 112
Coretti, S. 87
Corsalini, E. 16
Cruz e Silva, O. 106, 107
Dal Molin, M. 44
D'Amour, D. 92
Davidovitch, N.105
De Regge, M. 55
Deales, A. 14
Degadt, P. 55
Del Pino, V.16, 17
Derbissalina, G. 122
Deufert, D. 42
Dey, P. 60
Dobrick, K. 67

Dopelt, K. 105
Dotti, C. 26
Dubois, C. 92
Dueker, P. 94
Dussault, G.35
Duyck, P. 55
Edgren, G. 31
Exworthy, M. 74
Fameli, E.63
Farnschläder, J. 100
Fattore, G. 16
Fernández-Cano, P. 112
Ferreira, M. 106
Figueiras, A. 106, 107
Foglia, E. 26, 95
Fontana, G. 99
Forsberg, B. 31, 33, 77
Freeman, T.53
Frey, B. 84
Friberg, A. 24
Fronteira, I. 35
Gabrani, A. 20
Gabrani, J. 20
Gemmel, P. 55
Giannantoni, P. 89, 90
Gillessen, A. 93
Girard, F. 92
Gitto, L. 90
Gitto, L. 89
Gonçalves, S. 88
Grancharova, G. 97
9
Grašič, K. 69
Gregório, J. 36
Grit, K. 65
Groth, A. 123
Grotto, I. 105
Haking, D. 124
Hänninen, M. 121
Hayen, A. 25
Hecke, T. L. 93
Heiligers, P. 113
Herdeiro, M.T. 106, 107
Högberg, M. 31
Höß, V. 120
Hristova, L. 126
Hyttinen, V.121
Hyttinen, V. 41
Iacopino, V. 117
Ivanov, I. 104
Janssen, M. 83
Junkmanns, C. 94
Kaarakainen, M. 41, 121
Kalediene R. 115
Kauronen, M. 108
Kettelgerdes, A. 93
Kirkpatrick, I. 22
Kirschner, M. 76
Klazinga, N.50
Klein, S. 94
Koduzi, G. 125
Koikov, V. 122
Korac, S. 45

Kounougeri Petsetaki, E. 30
Kruus, P. 72
Lapão Velez, L. 13, 35, 36, 48
Lau, M. 84
Lenhoff, H. 33
Leone, C. 13, 48
Leppik, L. 72
Lettermark, Y. 33
Litan, C. M. 39
LLewellyn, S. 74
Luijkx, K. 58
Lukšič, P. 69
Lyubomirova, K. 126
Mahon, A. 74
Mäki, S. 116
Malnis, D. 26
Mancusi, M. L. 87
Mannion, R. 53, 74
Mäntyranta, T. 116
Marcellusi, A. 89, 90
Martí, T. 27, 40
Mascia, D. 37, 86, 117
Masella, C. 44
Mazzone, A. 26
McNichol, E. 81
Meijboom, B. 25, 58
Millar, R. 53
Minkman, M. 64
Minvielle, E. 78
Mira, J.J. 112
Mircea Chereches, R. 39
10
Morandi, F. 37
Morando, V. 118
Morelli, P. 95
Mpoursanidis, C. 57
Muijsers, L. 46
Nardi, R. 99
Neves, C. 106
Nieri, S. 99
Nordblad, A. 116
Nuño, R. 112
Nyström, I. 77
Obradovid, A. 21
Obradovid, Z. 21
Olsson, E. 84
Orbanid, A. 69
Paavola, P. 116
Pavlova, J. 19, 104
Pekkola, J. 51
Pellegrino, S. 99
Pereira, H. 103
Peris, A. 27, 40
Petrela, E. 20
Piconi, I. 37, 86
Pisev, V. 19, 104
Plochg, T. 50
Pomey, M. 92
Porazzi, E. 26, 95
Pristas, I. 111
Putters, K. 83, 96
Raich, M. 42, 52
Räsänen, P. 110

Redondo, P. 56
Restelli, U. 26, 95
Rigby, M. 29
Robben, P. 65
Roine, R. P. 110
Rojnic Palavra, I. 111
Romeyke, T. 101
Roque, F. 106, 107
Ruggeri, M. 87, 109
Ruggeri, M. 14
Runå-Ljungberg, E. 84
Rus, I.A. 39
Ruspini, M. 95
Ryynänen, O. 110
Saliterer, I. 45
Santana, S. 56
Santos D. 103
Santos, D. 59
Santos, L. 59
Sarría, A. 16, 17
Sauliune, S. 115
Saverio Mennini, F. S. 89, 90
Schipper, L. 58
Schols, J. 58
Schüring, S. 123
Scolari, F. 26
Segato, F. 44
Sheaff, R. 74
Sijnave, B. 55
Sikkut, R. 72
Simões, A. 88
11
Sintonen, H. 110
Skoro, I. 21
Soares, S. 106, 107
Soderquist, E. 63
Solas, O. 112
Spandonaro, F. 87
Stäck, P. 31
Stankunas, M. 115
Stevanovic, R. 111
Stühlinger, V. 120
Stummer, H. 100, 101, 102, 120
Suomalainen, S. 41, 121
Temido, M. 35
Terekli, G. 98
Toro, N. 112
Tuppurainen, E. 116
Tzacheva, N. 19, 104, 126
Ungureanu, M. I. 39
van den Berg, M. 25
van der Lee, I. 113
van der Velden, L. 15
van Hassel, D. 15
Vasiliadou, C. 30
Vekov, T. 97
Veldre, V. 72
Vennik, F. 96
Verhaeghe, R. 55
Verheyen, F. 67
Veronisi, G. 22
Vietor, C. 93
von Eiff, W. 123, 124

Võrk, A. 72
Waelli, M. 78
Wagner, Ca. 67
Wagner, Co. 50
Weller, J. 93
Werr, J. 31
Westert, G. 25
Westling, J. 33
12
Westling, K. 77
Westlund, M. 84
Wulff, S. 41, 121
Yanakieva, A. 91
Yancheva, M. 126
Yazbeck, A. 69
Yildirim, T. 98
Zeulehner, C. 42

Special interest group:
Primary Care
Wednesday 13 June 2012,
13.30-15.00
13

Wednesday 13 June, 2012 13.00 -15.00
DEVELOPING CLINICAL GOVERNANCE INNOVATIVE PRACTICES IN PRIMARY-CARE: SELF-
ORGANIZATION AND VERTICAL INTEGRATION DYNAMICS
Luis Velez Lapão, Claudia Leone
Institute of Hygiene and Tropical Medicine, Lisbon, Portugal
CONTEXT
The Portuguese Primary Care Reform presents the opportunity to explore and improve the
management models and practices, promoting quality and a patient-oriented service. The aim of
the present investigation is to study the evolution (since 2009) and the impact of the management
practices of the Group of Health Centres (ACES), focusing in the implementation of clinical
governance (CG) and its linkage with the secondary care. Furthermore, we will take the opportunity
to study this dynamics by exploring the existence of two different vertical integration settings:
ACES that are formally involved in Local Health Units (LHU) and those who aren‟t.
METHODS
In order to respond to the objective of the present study, a qualitative approach together with an
action research methodology were considered. After a literature review to allow a better
understanding of different CG experiences in selected countries, the process of data collection
started through the elaboration of 12 focus groups and questionnaires applications, which are
currently taking place around the Portuguese territory. The aspects considered in the sessions are
related to the ACES performance and self-organization dynamics of ACES regarding clinical
governance in both different vertical integration settings. The data collected is analysed in order to
diagnose the evolution of the different management models and to identify good management and
clinical governance practices, which show the benefits and opportunities of continuity of care.
Additionally, we will evaluate the impact and the cost effectiveness of two different management,
and CG models, which have been developed at both organisational care settings.
RESULTS
The methodological design of the present study aims to contribute towards a better knowledge and
performance of the current management models responsible for the development and execution of
clinical governance along the Portuguese health system. The results so far have shown several
patterns of innovative action towards the development of a CG culture: the creation of clinical
councils with the responsibility to tackle CG, the creation of expert groups to promote and share
best practices, etc. In addition, we have found out the emergence of complex behaviour among the
interactions between the different levels of services related with clinical governance. Regarding the
study of CG at two health care settings of vertical integrations, a better understanding of the
impact/cost effectiveness of health management and clinical governance was obtained: A SWOT
analysis on both setting will be presented.
CONCLUSIONS
In order to improve healthcare services from vertical integration (ACES formally involved in LHU),
one should considered two important conditions: a clinical governance model that enable the
alignment of activities between the primary and the secondary care; and the existence of an
Information Systems for registering and sharing clinical records that will allow an improved
management performance and CG decision-making. Both conditions were evaluated in the present
study. A better understanding of best fitted CG models, applied by the Group of Health Centres
while tackling quality improvements, is a critical matter. Therefore, it is of immense relevance to
understand how these models could be developed to strengthen the decision-making and the
capacity to manage the interface with secondary care.
14

ASSESSING THE ECONOMIC IMPACT OF DISEASE MANAGEMENT PROGRAMS TO PREVENT
CARDIOVASCULAR DISEASES IN ITALY: THE RAFFAELLO PROGRAM
Matteo Ruggeri1, Americo Cicchetti1, Alberto Deales2
1 Università Cattolica del Sacro Cuore, Roma, Italy, 2 Agenzia Servizi Sanitari Regionali, Ancona, Italy
CONTEXT
Cardiovascular diseases represent an important source of absorption of resources for modern
health systems. The purpose of the project is to demonstrate how a new model of care, which
empowers the patient at risk for cardiovascular events, produce better clinical outcomes and a
favourable cost effectiveness ratio.
METHODS
The study was carried out by designing a cluster randomized controlled trial. The program
involved the application of innovative methodologies of Disease and Care Management to
monitor and measure the effectiveness and efficiency of care processes for chronic diseases. A
Care Manager helped the patient to follow the care plan established by the physician, measured
the improvement in health status of the patient and assessed her care needs. From June 2007
to June 2009 cost and QoL data were collected in four territorial health organizations in the
Marche region. Patients enrolled were taken in charge by Care managers in two health
organizations and followed the traditional care pathway in the other two health organizations.
Cost data concerned the consumption of drugs, diagnostic exams, specialist visits, and
hospitalizations. Patients were also administered with the questionnaire EQ-5D. A probabilistic
sensitivity analysis was conducted to test the robustness of results.
RESULTS
The results allow to place the cost-effectiveness of the Disease Management program within a
hypothetical threshold of EUR 20,000-30,000 per QALY. In particular, the base case shows an
ICER of EUR 12,000 per QALY. For the age group between 55 and 60 years the costeffectiveness
of the Disease Management program was dominant in comparison with the
traditional care pathway.
CONCLUSIONS
This study represents the first example in Italy of an economic evaluation conducted on the
basis of a cluster randomized trial. Also for the first time were detected, using the EQ-5D, the
coefficients of utility concerning a sample of 9000 individuals representative of the Italian
population. In conclusion it can be stated that the application of innovative methodologies and
technologies of Disease and Care Management presents a sustainable cost-effectiveness ratio.
In view of the considerable economic impact that chronic cardiovascular diseases have on
regional health systems, this project adds relevant information in view of decision-making and
health planning.
15

WORKING AS A LOCUM GP: THEIR PROFESSIONAL ROLE IN ORGANIZATIONAL CONTEXT
Ronald Batenburg, Daniel van Hassel, Lud van der Velden
NIVEL, Utrecht, The Netherlands
CONTEXT
The workforce of General Practitioners (GPs) in the Netherlands is closely monitored and planned to
ensure their pivotal role in primary care and the Dutch health care system. While the majority of GPs
have their own practice or are employed by other GP practices or health community centres, a
relatively small but important group are GP locums (GPs on call). This group is hard to monitor as
there are frequently changing work locations and have a deviant (i.e. more dynamic) career pattern.
Still, the contribution of GP locums to the flexibility of the GP workforce is of increased importance.
METHODS
All GPs that were a member of the Dutch GP Association (LHV) and indicated that they primarily
work on call, received an on-line questionnaire in the spring of 2010 and the spring of 2011. In
2010 34% of the 1,460 GPs approached responded, in 23% of the 1,491. With the survey, the GP
locums were queried about their motives and preferences with regard to their duties. Other
questions informed about the type of tasks, their professional role and the type of practices they
work for. The attitude and behaviour of the GP locums can be related to a number of background
characteristics. Most importantly, we applied bivariate and multivariate analyses to explore the role
of gender and career phase on the different profiles of the GP locums, which can be empirically
created using the survey data.
RESULTS
A basic profile distinction that be seen between GP locums that are at the beginning of their career
and those that are longer ahead in their working life after being registered as a GP. Older and more
experienced GP locums tend to work for fewer different and changing practices, while the younger
GPs work more hours and shifts for more employers. Motives also differ between these two groups.
While starting GP locums are often driven by financial motives, experienced GP locums merely
prefer working independently, not being responsible for management duties. Interesting profile
differences also occur between men and women. Female GP locums indicate to aim for a salaried
position in a later career stage and prefer the flexibility of their position, while male GP locums aim
for practice ownership and are significantly more willing to move locations.
CONCLUSIONS
GPs on call, GP locums, are an important group as a highly flexible segment of the Dutch GP
workforce. From our survey, this group appears to be quite diverse in composition, behaviour and
attitude. These differences are important to acknowledge in monitoring and „planning' the GP
locums. Given the increased pressure on health care costs and quality assurance in primary care, it
is recommended to specifically regard how GP locums can optimally contribute to the future
challenges. As this group frequency changes employers, some other actor or organization should
provide some human resource policy to support them. Some temporary employment agency appear
to play such a role, but it can be useful to create other institutions they guide GP locums through
their career and most importantly, retain their capacity the future workforce needs in a developed
primary care system.
16

CLINICAL VIGNETTES: A TIME-DRIVEN ACTIVITY BASED METHOD FOR MEASURING MICRO-
COSTS IN PRIMARY CARE IN EUROPE
Antonio Sarría1, Giovanni Fattore2, Virginia Del Pino1, Almudena Albertos1, Eleonora Corsalini2
1 Instituto de Salud Carlos III, Madrid, Spain, 2 Bocconi University, Milan, Italy
CONTEXT
EUPRIMECARE is a project funded by the 7 th Framework whose objective is to analyze the costs and
the quality of care of different primary care models in Europe. The objective of this abstract is to
provide a methodology to measure and compare micro-costs incurred in taking care of four types of
patients in primary care in a comprehensive and reliable way, and to apply this methodology to
measure time and resources consumption in the delivery of services involved in those clinical cases
and to describe variability in how those cases are managed in different systems.
METHODS
A series of clinical vignettes or scenarios, which represent key aspects of primary care services,
were identified and selected by consensus among the partners of the consortium. The vignettes
finally selected define four relevant activities conducted in primary care: chronic care (an old women
with diabetes), acute care (a child with fever and respiratory symptoms), prevention (an old man
who wants to be vaccinated against the seasonal flu) and health promotion (a women is counselled
to quit smoking). These vignettes were constructed in English and translated into local languages,
being validated by primary care professionals. They were then sent for completion to different
primary health care professionals (doctors, pediatricians, nurses) in each of the participating
countries. Costing will be assessed through Time-Driven Activity Based Costing, being the main
domains of information which has been collected time of professionals devoted to care for those
cases and its cost.
RESULTS
The information gathered from the questionnaires will be included in a database and analyzed
qualitatively and quantitatively. We were able to collect information from 23 primary care doctors
and nurses, as well as from 19 primary care pediatricians. The basic unit of measure was the time
spent by the different professionals involved in each clinical scenario. Information has also been
collected regarding the consumption of resources estimated to be required for caring for those
patients. The next step will be to attribute monetary values to that spent time and resource
consumption. Vignettes will provide with a comparable estimation of costs, and permit the analysis
of variation on how the same cases are managed within and between countries. Despite the
variability of the provision of healthcare services in each country, the cost per hour worked will
serve to assess clinical contexts in the most consistent way.
CONCLUSIONS
Not all the patients are the same nor require the same amount of time. Not all the payment
mechanisms are the same in every country and there are different ways to provide the same
healthcare service. However, the unit object of the comparison of primary care micro-costing will be
the time. For that reason, this methodology could be extended and applied both to other European
countries and to other health problems, providing a sensible picture of costs associated with
primary care services.
17

A PROPOSAL TO DEFINE A FRAMEWORK TO CLASSIFICATION MODELS OF PRIMARY CARE IN
EUROPE.
Antonio Sarría, Virginia del Pino, Almudena Albertos
Instituto de Salud Carlos III, Madrid, Spain
CONTEXT
EUPRIMECARE is a project funded by the 7 th Framework whose objective is to analyze the costs and
the quality of care of different primary care models in Europe. The objective of this abstract is to
describe a methodological approach to characterize models of primary care in Europe, defining a
framework of existing European models of primary care, which will allow for assessing costs and
quality across models.
METHODS
A literature review was carried out to identify publications which assess and describe characteristics
of primary care. The electronic literature search was restricted to English language journals and
studies published in the last 5 years. Online and manual searches were also conducted to identify
all types of publications which could include information valuable for our objectives. Through
consensus a number of components of primary care which could be considered as predictors of
cost and quality were identified and classified under five control knobs: finance, payment,
organization, regulation, and organizational Behaviour. A template that included an extended list of
specific issues which could be classified under those five domains were elaborated and filled with
information from the national specific characteristics of primary care systems of Estonia, Hungary,
Finland, Germany, Italy, Lithuania, and Spain. With this information both a qualitative and a
quantitative analysis were conducted.
RESULTS
The qualitative analysis, based on a functional perspective, allowed to proposing five models: Direct
access to any GP or specialist; Referral required from GP, mainly solo-practices in PHC; Referral
required from GP, mainly group-practices in PHC; GPs working mainly in health care centres; and
Polyclinics. The quantitative analysis identified a series of characteristics that appear to be relevant
to develop a framework to classify model primary care systems: Provision of services through
national-regional/local system (Yes/No); Voluntary private insurance (Yes/No); Planned distribution
of primary care services (Yes/No); Professional income (Capitation/Salary/Fee for service/Out of
pocket); Gatekeeping to specialists (Yes/No); Type of facilities (Public/Private); Type of practice
(solo /Group/Integrated network); Formal quality management & improvement programmes
(Yes/No); Continuing clinical education programmes (Yes/No); and Local adaptation of clinical
guidelines (Yes/No).
CONCLUSIONS
This proposal advances the traditional and simplistic classification of health systems in two broad
categories: Beveridge and Bismarck. The main value of this framework is that it is based on a
multidimensional, and therefore, more complex and realistic characterization of health care models
taking into consideration very specific characteristics aggregated under five domains (financing,
regulation, payment, organization and organizational behaviour). Also it has to be mentioned that
very specific focuses on primary care. A limitation of this work is that is based on information only
from the 7 countries participating in EUPRIMECARE, but this work is being validated with
information collected through a reduced template from OECD countries.
18

Special interest group:
Healthcare Workforce Management
Wednesday 13 June 2012,
13.30-15.30
19

ACHIEVEMENT OF PATIENT SAFETY THROUGH QUALITY OCCUPATIONAL HEALTH
MANAGEMENT IN BULGARIA
Nevena Tzacheva, Jasmine Pavlova, Vasil Pisev, Lydia Christova
FPH, MU, Sofia, Bulgaria
CONTEXT
In recent years, after the timely transposition of the Water Framework Directive 89/391/EEC of
12.6.1989, the Law on health and safety of 23.12.1997 and ratification of Convention 161 on
Occupational Health Services since 1985. ILO, Bulgaria has achieved better health and economic
impact on the safety of services including users of medical services. These documents include an
aspect of health and occupational management for quality health activities to objectify the
relationship "good working conditions - reducing the expenditure benefits for diseases and injuries
of medical professionals - the release of financial resources to ensure quality and safety of
patients".
METHODS
Material and methods: This study aims the monitoring of total employment losses due to temporary
disability, sickness and accidents for a three year period in two university hospitals - Paediatrics and
Pulmonology, and the opportunities for promotion of health and safety of patients served. To
achieve the objective we set the following tasks:
� Risk assessment of jobs, including safety in the diagnosis and treatment of patients;
� Assessment and dynamic monitoring of the health status of medical specialists with
emphasis on the temporary disability and work loss;
� Calculation of compensation for absence from work due to illness and / or accident.
Studied 250 medical specialists. Survey period: 2006 – 2008. Compensations are calculated based
on data from the National Insurance Institute. We used the documentary, risk assessment, inquiry
and expert method.
RESULTS
The ratio of working women/men is 21% to 79%. The average age was 49.5 for men and 37.3 years
for women. For the first hospital - Paediatrics – in 67% of workplaces risk assessment is ranged
from 70 to 200 points, which indicates "acceptable" and "allowable" professional risk. The health
status calculated by dividing the level of employment loss of total temporary disability is 1083.6
per 100 workers. Employment losses in this hospital also decrease from 269.0 to 234.0 or 258.8 on
average during this period of observation. For the second hospital - Pulmonology - the risk
assessment shows that in 72% it is acceptable or is considered unlikely to harm the health of staff
or patients. Relevant data are: average level of 1326.8 are for 2006 - 1580.0 and employment
losses for 2010 - 1094.0 employment loss per 100 physicians.
CONCLUSIONS
Data from the risk assessment of work places of medical professionals in both hospitals for
diagnosis and treatment of patients has been very satisfactory. Data on health status are different
in the two hospitals regardless of good working conditions. This largely reflects the quality of
medical services and patient safety. In the prospective study of these hospitals were included
criteria for satisfaction of patients and their families and suggestions for improving the quality and
safety. In conclusion we found the need to promote health managers to guide the saved financial
resources to increase service quality and patient safety. The development of health management
activities towards seeking links between the overall hospital profile including.
"Labour good medical practice" with the economic benefits of reducing the incidence of medical
professionals and to improve the safety of the "common area" – the work place and the place to
diagnose and treat patients.
20

PATIENT SAFETY IN PRIMARY CARE IN ALBANIA
Adriatik Gabrani1, Jonila Gabrani1 ,2, Eliziana Petrela1 ,3
1 University of Tirana,Tirana, Albania, Albania, 2 Kristal University, Tirana, Albania, Albania, 3 Lady of Good Will University,
Tirana, Albania, Albania
CONTEXT
Patient safety is an issue of global importance. Reports highlight better understanding of the causes
and harm of adverse events in developing countries and those with economies in transition. Albania
represents a typical case on which researchers strive to obtain "available data" in order to evaluate
patient safety. Healthcare in Albania is mainly public. It consists of Primary Care, hospitals and
scientific research. The Primary healthcare workers number is 9350, 2000 physicians, 6600 nurses.
In such situation we thought to conduct a study in order to obtain the real perception on patient
safety, from the Primary healthcare workforce perspective.
METHODS
The Safety Attitude Questionnaire is questionnaire with 60 items and demographics information
(age, sex, experience, and district). Each of the 60 items is answered using a five-point Likert scale
(Disagree Strongly, Disagree Slightly, Neutral, Agree Slightly, and Agree Strongly). There are 7
domains: Teamwork Climate, Safety Climate, Job Satisfaction, Stress Recognition, Perceptions of
Primary Care Management and Working conditions. There were assembled 526 questionnaires from
all over Albania, primary care workforce .There is also an open-ended section for comments which
we preferred to directly obtain workforce free-comments or perceptions that they had about the
theme. The Scale Computation was also calculated providing so general descriptive information at
the Item Level, Likert scale: Percent Missing Data; Overall Mean (Standard Deviation); Overall Percent
Agree; Item Skewness; Item Kurtosis. Crosstabs performed of several domains between male and
female, physicians and non physicians. T-test and Sample Independent tests were also performed.
RESULTS
Teamwork Climate, 89% agreed to "The physicians and nurses here work together as a wellcoordinated
team" 36% agreed also to "In this ambulance, it is difficult to speak up if I perceive a
problem with patient care". Safety Climate: "Medical errors are handled appropriately", more
doctors than nurses affirm the item (p = 0.001). Also, more doctors than nurses affirm that "I know
the proper channels where to direct questions regarding the safety of the patient" (p = 0009). 77.
Stress Recognition: "When my workload becomes excessive, my performance is impaired" only
39.2 % agreed. Only (36%) of nurses and (41%) physicians affirm that they might make errors in
tense situations (p = 0004). 3% of physicians and 10% of nurses, claim that fatigue lowers their
performance during the routine, (p = 0002). Perceptions of Management: no statistically
significant difference between doctors and nurses were noticed. No gender difference.
CONCLUSIONS
There has been given little attention to safety attitude or medical errors in Albania. No formal
studies have been conducted on this issue on Primary Care. Error is difficult to discuss in medicine
and not all staff accept personal involvement to error. Promiscuous results on stress and fatigue
recognition. Medical staff shows unawareness to the likelihood of making errors in tense situations.
Gender Issue: There was no statistical difference observed, between male and female on Stress
issue. Hierarchy Issue: Nurses feel more intimidated on reporting errors compared to physicians.
Elements on job satisfaction should be reviewed from policymakers since there is statistically
significant difference between doctors and nurses. A statistical significant difference on channels of
information is also observed, on which nurses feel less confident. Anyway, it does exist a positive
management perception since both nurses and doctors claimed to be affirmative on total
management items.
21

NURSES AND BURN-OUT AT WORK PLACE
Zarema Obradovid1 ,2, Ifeta Skoro3, Amina Obradovid4
1 Institute for Public Health of Canton Sarajevo, Sarajevo, Bosnia and Herzegovina, 2 Faculty for Health Studies, Sarajevo,
Bosnia and Herzegovina, 3 RMC"Dr Safet Mujic", Mostar, Bosnia and Herzegovina, 4 CEEC CONSULTING, Sarajevo, Bosnia
and Herzegovina
CONTEXT
The work of nurses is very human because they help people in saving their health and protection
against diseases. Nurses are the largest group of health workers and all the problems that appear in
the health system are first recognized among them. One of the problems which appear among
employed people of all profiles, and among them nurses, is the burnout syndrome. The aim of our
work is to investigate the presence of factors which lead to the burnout syndrome among workers
in RMC „Dr Safet Mujić“ in Mostar, Bosnia and Herzegovina.
METHODS
The study was made by anonymous questionnaire which consisted of 20 questions. Total of 105
nurses of RMC „Dr Safet Mujid“ Mostar were questions, from which some were working in hospital
and some in outpatient sector. Study was made in period January to September 2011.
RESULTS
In this study 77,9% nurses work in hospital sector. Over a half of examinees (52%) has over 16 years
of work experience. Only 34,6% is satisfied with interpersonal relationships, and only 31,7% is
satisfied with their relationship with the superior. Motivation for work have only 51% of examinees,
a big number comes unwillingly on their work and is looking forward to leave. One of the reasons
for unsatisfaction is overwork which thinks 83,7% and 71,2% thinks that they can't make progress
on their work. It is good that a big number of examinees (85,6%) doesn't think about problems
related to work outside their working hours, but still a good sleep have only 38,5% of examinees
and 56,7% wakes up tired. 58,7% of examinees would like to change their working place.
CONCLUSIONS
Nurses employed in RMC „Dr Safet Mujić“in Mostar are during their work exposed to many factors
which can cause the burnout syndrome. It is necessary to expand the study on a larger group of
nurses and to plan and continuously implement the measures for reducing risks of burnout
syndrome according to the results of the study.
22

CLINICIANS ON BOARD: WHAT DIFFERENCE DOES IT MAKE TO HOSPITAL PERFORMANCE?
Gianluca Veronisi, Ian Kirkpatrick (presented by Kathy Hartley)
Leeds University Business School, Leeds, UK
CONTEXT
For the past two decades there has been a marked policy shift to encourage doctors and other
clinicians to become more involved in management roles. However, it is open to question how
much difference this will make to the performance of services. While some studies find a strong
correlation between hospital quality rankings and patient satisfaction and clinical involvement
Goodall (2011; Dorgan et al., 2010), others are more sceptical. As such this paper aims to
contribute to this debate drawing on routine data on board membership in NHS (UK) hospital trusts
and outcomes for efficiency and service quality.
METHODS
The analysis is based on an original dataset of 170 English NHS acute hospital trusts. Details on
the composition of the board of directors - including the professional and educational background
of each director - were collected manually from the trusts' annual reports and websites. The
performances of public hospitals are also publicly available and accessible from the Care and
Quality Commission library. The data used in the study are referred to the period starting from
2005/06 to 2008/09. The professional and educational background of a director is used to
determine the type of expertise that each director brings to the overall board decision making
process. A panel data with fixed effect model is adopted to test the main hypothesis, which is that
trusts with a greater clinical leadership will perform better than other trusts where clinicians have a
limited presence at the board level.
RESULTS
Descriptive statistics show remarkable difference between boards in relation to the predominant
type of expertise of board directors and the overall performance of hospitals. Overall clinicians hold
only a small minority of Chair and CEO posts and are a minority presence on the boards of most UK
hospital trusts. In 2008/09 out of 102 trusts, only 6 (5.9%) are chaired by a clinician and 23 (22.5%)
have a clinician CEO. Interestingly, there are more clinicians on boards of teaching hospitals,
hospitals that serve larger populations and have clinician CEOs. Surprisingly fewer clinicians were
present on the boards of „Foundation trusts' - hospitals which had been granted more autonomy to
manage their affairs. With regard to performance the results showed a weak positive correlation
between higher clinician involvement on board‟s outcomes for service quality. However, there was
no significant relationship between clinician involvement and improved efficiency.
CONCLUSIONS
These findings are perhaps surprising given the sustained efforts in the UK to persuade clinicians to
enter management roles, and raise questions about the effectiveness of recent health management
reforms. Hospital trusts continue to be dominated by non-clinical professions such as accountants,
business managers and NHS administrators. This is in marked contrast to some other European
health systems such as Denmark, Norway and Italy, where doctors make up almost 50% of all
hospital CEOs. However, at the same time, our findings support the argument that clinical
involvement at more strategic levels within hospitals can make a difference, especially in terms of
service quality. Such findings point to the need for policy makers to renew their efforts to support
doctors and other clinicians in management roles through improved incentives, training and career
planning. Having clinicians „on board' is not just window dressing - it can have significant
performance benefits!
23

Parallel Session:
Primary Care and Financial Incentives
Thursday 14 June 2012,
11.00-12.30
24

ECONOMIC INCENTIVE – ONE WAY OF PROMOTING PATIENTS’ HEALTH GAIN IN THE HEALTH
CARE SYSTEM
Anna Friberg
County of Skåne, Malmö, Skåne, Sweden
CONTEXT
A great part of cardiovascular and common cancer diseases are linked to life-style factors. The
health care sector is one of many important arenas where health promoting and disease preventing
activities must develop and take place. The clinical staff, all categories among all providers, has a
key role in motivating the patients to do life-style changes. A model of economic incentives has
been developed and implemented in the health care sector in the county of Skåne Sweden, in order
to stimulate the clinical staff to identify adverse life-style habits and initiate life-style changes.
METHODS
The economic incentive is a pay-for-performance model and builds up in different steps. The
performance consists of identifying adverse life-style, initiating the correct treatment (i.e motivating
the patient to do life-style changes) and to follow up the outcome of the treatment in terms of
patient-reported health status. Both outpatient hospital and psychiatrist settings, (only public
providers) and the primary care units (public and private providers) are included in the model. The
county council in Skåne has allocated 20 million SEK to the hospital and psychiatrist sector yearly
since 2009 and 16 million SEK to the primary care since 2011 (total yearly budget is appr. 30 billion
SEK). The hospital and psychiatrist units report the performances via the electronic patient records
and they receive the payment quarterly. The primary care units are receiving a "structural" payment
in exchange for organizing their promoting and preventing activities.
RESULTS
As of end 2011 all eight hospitals, including the university hospital and the psychiatrist outpatient
settings, have started performing and documenting their life-style interventions in a more
systematic way. Special life-style units have been developed in all hospitals. But the result measured
with registered life-style interventions differ substantially between the hospitals mostly due to
differences in the local prerequisites regarding resources for implementing and informing about the
concept and the economic model. Out of approximately 160 units of primary care, 120 have started
to work more systematically with health promotion and prevention and have thus qualified to share
the "structural" payment.
CONCLUSIONS
Economic incentives can be used to focus on health promotion in both hospital/psychiatrist settings
and in primary care units. Economic incentives have a strong effect on both the management level
and on the clinical staff level. In order to be even more successful in health orientating the health
care system it must be as easy to perform health promoting and preventing activities as it is to
perform "ordinary" care activities. The electronic patient records must develop. The competence
among the clinical staff on patient centered care and cognitive behavioural theories must enhance.
And last, but not least, the question of health orientation must be on the top list of the agenda of
important issues concerning the development of the health care system as a whole.
25

SHARED SAVINGS BETWEEN PAYERS AND PROVIDERS OF HEALTH CARE: PRELIMINARY
FINDINGS FROM A CASE STUDY IN THE NETHERLANDS
Arthur Hayen1, Michael van den Berg2, Bert Meijboom1, Gert Westert3
1 Tilburg University, Tilburg, The Netherlands, 2 National Institute for Public Health and the Environment, Bilthoven, The
Netherlands, 3 Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
CONTEXT
In various countries (e.g. US, UK, the Netherlands) payers of health care try to get more value for
money by changing accountability relationships. To this end, groups of care providers are held
accountable for the care received by the populations of beneficiaries they serve. Shifting
accountability to care providers is increasingly combined with a shared savings approach, under
which care providers share in the savings they generate conditional on the achievement of quality
targets. We developed a shared savings model for a large Dutch health insurer and contracted care
providers.
METHODS
We analyzed the literature on determinants of health care costs and studied various shared savings
approaches. From these initiatives, we distilled five building blocks that together make up a shared
savings model. These building blocks are: „defining accountability', „calculating health care costs',
„defining the benchmark', „calculating savings', and „distributing shared savings'. The resulting
model was implemented and its implications were tested using data on health care use, costs and
quality. The data were drawn from the health insurer's reimbursement data, linked with routinely
collected patient data and administration data of the care providers. These data, supplemented with
regional demographic data, allow for a rich case mix correction.
RESULTS
We analyze trends in realized savings at the level of the health care centre, and compare these
trends with those of control groups at the local, regional and national level. Apart from using these
control groups, our empirical design (panel data) allowed for the calculation of a historical trend as
well. Besides cost trends, we address trends in health care quality. These trends give insight into
whether the implementation of a shared savings model leads to better adherence to guidelines and
better quality in general. The results are interpreted using transaction cost theory, as a shared
savings model changes the contractual relationship between payer and provider of care.
CONCLUSIONS
Within several national health care systems (e.g. US, the Netherlands), fee-for-service
reimbursement schemes are common. From the viewpoint of transaction cost theory, these
reimbursement schemes pave the way for supplier-induced demand, do not encourage care
providers to coordinate their activities with other involved care providers, and invites care providers
to skimp on those dimensions of output that are difficult to measure. More general, when care
providers' income depends on the number of medical services provided, they will accept little
steering of behaviour as this will directly affect their income. A shared savings model loosens the
relationship between production and income, especially when savings are distributed conditional on
achieving quality targets. With the implementation of a shared savings model, the health insurer
therefore has the opportunity to steer behaviour. Shared savings models between payers and
providers of care thus have the potential to increase value for money in health care.
26

INTEGRATED OR NOT INTEGRATED? WHAT FUTURE FOR PCGS?
Francesca Scolari1, Emanuela Foglia1, Emanuele Porazzi1, Umberto Restelli1, Daniela Malnis2, Giovanni Beghi2,
Antonino Mazzone3, Carla Dotti3
1 Centre for Research on Health Econoimcs, Social and Health Care Management (CREMS), Università Carlo Cattaneo -
LIUC, Castellanza (VA), Italy, 2 Local Health Authority Milano 1, Legnano (MI), Italy, 3 Hospital Authority Ospedale Civile di
Legnano, Legnano (MI), Italy
CONTEXT
Discontinuity of care at the interface between inpatient and outpatient management can lead to
increased morbidity and mortality (Tandjung et al., 2011). Evidences of the effectiveness of
associative models of primary care in chronic diseases are presented in literature (Bodenheimer et
al., 2002; Olivarius, 2001). Other Italian studies have demonstrated higher performances of GPs
networks and groups, compared with individual practitioners (Mannino et al., 2009). Who cares and
how cares (are provided)? These are the key questions.
METHODS
In 2008, a pilot project of territorial integration between the Local Health Authority Milano 1
(District 4 - Legnano) and Hospital Authority Ospedale Civile di Legnano was implemented in 3
PCGs. In 2010 this project involved 5 PCGs with 40,900 patients. During the observation period (3
years) cardiologists and internal medicine specialists provided consultancy services for the PCGs.
Once every week specialists performed visits and consultations at the practitioners office. Starting
from the reprocessing of the LHA Milano 1 administrative data, this study investigated the impact of
PCGs activity on the overall performance of District 4 - Legnano, compared with those of the LHA
Milano 1, and the impact on the mortality rate.
RESULTS
In the three years of activity, there was a reduction in the overall percentage of patients affected by
chronic diseases: e.g. from 217 patients with diabetes mellitus in 2008, to 192 in 2010. The
comparison between the number of dyslipidemic patients followed by PCGs of District 4 and the
LHA Milano 1, shows a decrease in admissions into hospital for heart failure, angina, and ischemia
(4.7 - 4.1 per 1,000 inhabitants vs. 5.29 - 4.62 per 1,000 inhabitants for LHA Milano 1), as well as
ischemia (3.01 District 4 vs. 3.33 LHA Milano 1, in 2010) and hypertension (0.14 vs. 0.4).
CONCLUSIONS
This study demonstrates the importance to focus on new organisational models, with pathways that
link practitioners and hospitals specialists, in order to improve the quality of the services provided.
There was evidence that, within District 4 - Legnano, the admissions rate per thousand inhabitants,
is lower than the one of the overall LHA Milano 1: efficiency and appropriateness increase lead to an
improvement of quality. For these reasons it is consistent to study the results in terms of hard
endpoint and to investigate the reduction in terms of deaths.
27

PROVIDER STRATEGIES IN THE DOWNTURN: THE POWER OF ECONOMIC INCENTIVES TO
PRIMARY CARE RESOLUTION IMPROVEMENT
Tino Martí, Antoni Peris, Alba Brugués
CASAP, Castelldefels, Spain
CONTEXT
Catalan public health system has universal and nearly free coverage. Financed through taxes, public
autonomic purchaser (Catsalut) buys services from different health providers. There is a basic
service basket expanded locally according to population needs and provider resources. Primary care
financing comes mainly from contract with Catsalut that comprehends all activities and sets certain
objectives related to drug prescription, health promotion and chronic disease control linking them
with a 15% of yearly budget. There is no specific incentive for quality or service basket
improvements. Health care cut might affect those services not incentivised.
METHODS
A series of cost-effectiveness and cost analytics were performed to assess the allocation of
resources to health services provided out of the defined benefit basket and pay for performance
schemes. These health services include prick test and allergy studies, capillary test for oral
anticoagulant control, non midriatic retinography for early detection of diabetic eye disease and
treatment procedures such as minor surgery and criotherapy.
RESULTS
None of these services has been economically acknowledged in contract. For many years a
territorial basis on health needs and policies has been considered but so far nothing has been
defined. Different providers have same basket service in spite of low disease prevalence and low
procedure efficiency. Main results show cost-effectiveness of performing these services in Primary
Care.
CONCLUSIONS
A new model of purchasing and paying services should be defined in short time to introduce the
right incentive for primary care resolution. However, improving accessibility and resolution is
expensive although patients and professionals may be satisfied.
28

Parallel Session:
Evidence Based Planning
Thursday 14 June 2012,
11.00-12.30
29

RESEARCH INVENTORY OF CHILD HEALTH IN EUROPE (RICHE) - AN EU PROJECT FOR
SYSTEMATIC COLLECTION AND PRESENTATION OF EVIDENCE
Michael Rigby1 ,2, Denise Alexander2
1 Keele University, Keele, UK, 2 Nordic School of Public Health, Gothenburg, Sweden
CONTEXT
Healthcare policy is too often based on belief (professional or political), a desire for change, or
other reactive stimuli. Within the important area of Child Health, the RICHE project (February 2010 -
January 2013) was designed, and accepted for funding by the European Commission, to identify all
recent research in child health. While the primary aim is to use this knowledge base to design a
targeted plan for future child health research funding, an important secondary objective is to create
a searchable database available to policy makers and other users to source sound evidence to
underpin policy making.
METHODS
Within the project, one work package was responsible for designing the inventory of research. The
first requirement was to construct a taxonomy within which to categorise and tag all entries, so
they could easily be found by non-technical users, searching using their own terms. Drawing from
a wide range of literature, a multi-axial taxonomy was created. A web platform was then
customised round this, to enable uploading of items and searching for them, with user needs being
the over-riding design priority. Three categories of research evidence were accommodated - peer
reviewed publications; grey literature (including policy reports); and summaries of research in
hand. Project members and other contacts were then encouraged to upload material from their
own countries, while the project researchers searched for European and other international
material. The site is language neutral, with the taxonomy being in English but with translation (and
vernacular synonyms) in nine other languages.
RESULTS
The taxonomy was created, and validated by a structured process involving selected users in
different countries, using both „use question' searches designed to seek evidence on locally
selected topics, and by selective loading of eclectic material. Following review, the taxonomy and
the web platform were fine-tuned, and went live for use in Autumn 2011. The uploading process is
now under way, with (February 2012) 195 entries from 18 countries. By June 2012 this process
should be mature. Already one country has loaded a significant national research database, making
this available internationally. By June 2012 analysis of the type and spread of material, and of usage
statistics, should be possible.
CONCLUSIONS
It is reasonable to expect policy making on healthcare provision (including preventive services and
health-related policy) to be evidence based, but all too often this is not the case. One of the prime
reasons is that the evidence is hard for non-academics, such as policy makers, regulatory bodies,
private provider managers, and the press and public, to find. The secondary aim of the RICHE
project, to collate and make readily available such evidence, including reviews and policy
assessments from other countries, is an important step in addressing this knowledge gap. A key
final step of the project will be to evaluate this availability and its impact. A further issue is the
seeking of ongoing funding, as currently this is a fixed-term research project under the EU
Framework 7 programme.
30

MANAGEMENT CAPACITY OF GREEK HOSPITALS - A CASE STUDY IN THE DEVELOPMENT OF
STRATEGIC MANAGEMENT PLANS
Elisabeth Kounougeri Petsetaki1, Cornilia Vasiliadou 2
1 National School of Public Health, Athens, Greece, 2 Department of Economics Attica Psychiatric Hospital Attica, Athens,
Greece
CONTEXT
The management capacity of Greek hospitals in the public sector has been under scrutiny for many
years with questionable outcomes in terms of the implementation of sound management practices.
The legalistic solution of imposing modern management practices has had its difficulties in terms
of what is legislated and what is actually implemented. Law no. 2889/2001 specified the
components of the strategic management plans (SMP) in the Regional Health Directorates (RHD) and
public hospitals. This case study analyses the strategy, the methodology, and the whole
conceptualization process of producing the SMP.
METHODS
The study focuses on the conceptualization process of producing SMP by the Regional Health
Authorities and the public hospitals in alignment with policies of the Ministry of Health. The process
is analysed from formulation of law No. 2889/2001 to the production of a manual and training
strategy to the development of the SMP. The SMP of 10 public hospitals and one Regional Health
Authority are analysed in the greater Athens area. A questionnaire was sent to the CEO to discern
the process of producing the SMP. Interviews with the CEO were also sought but not successful. The
training process for the staff on developing the SMP is also analysed.
RESULTS
The development of SMP is a complex process requiring technical knowhow and experience. In
addition it requires exceptional managerial skills to apply such a process in an organizational
setting with little tradition in organization and planning. Knowledge of change management,
empowerment of key managers and experience is essential for a successful outcome. The majority
of hospitals resorted to outside consultants to produce the manuals. Participation of key
management staff was absent. The SMP produced lack key data on both human and financial
resources. Data produced on utilization of services is minimal. The training for the production of
the SMP was neither coordinated nor thorough.
CONCLUSIONS
The development of a management capacity in the hospital setting requires leadership skills at
many levels of the health care system. The utilization of a management tool independent of a
modern management culture is the ban date solution to managing complex organizations. Training
and participation is key to successful outcomes.
31

PREDICTION OF UNPLANNED READMISSION AMONG HOSPITALIZED PATIENTS IN STOCKHOLM
COUNTY COUNCIL: A POPULATION BASED COHORT STUDY
Gustaf Edgren2, Michael Högberg1, Patrik Stäck4, Birger Forsberg1 ,5, Joachim Werr3
1 Dept of Development, Stockholm County Council, Stockholm, Sweden, 2 Dept of Medical Epidemiology and Biostatistics,
Karolinska Institutet, Stockholm, Sweden, 3 Health Navigator, Stockholm, Sweden, 4 Ernst&Young, Stockholm, Sweden,
5 Dept Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
CONTEXT
Data from 2009 show that 1% of the population in Stockholm county account for approximately 33%
of total health care costs. With an average of more than 3 hospital admissions per year and health
care costs averaging 39,000 € annually, this patient group is a strong driver of health care costs
within the county. Importantly, there is a significant turnover in this group as on a yearly basis 80%
are replaced by new individuals. To guide interventions designed to reduce admission rates among
these patients, we developed a prediction model to allow rapid identification of patients with high
readmission risk.
METHODS
All patients age 18 or older with at least one completed hospitalization between 2007 and 2010
were identified using complete and up to date databases encompassing virtually all in- and
outpatient visits within the county. Using de-identified, but individually unique personal
identification numbers, all health care contacts pertaining to the same patients were linked. For
each completed hospitalization, henceforth referred to as index hospitalization, we ascertained the
number and total length of previous hospitalizations, existence of selected previous and current
diagnoses, as well as the patients‟ age, sex, and socioeconomic status. In addition, we also
ascertained 90 day readmissions. We established a main cohort, with all patients, and three subcohorts
comprising patients aged 65 or older, patients with chronic obstructive pulmonary disease
(COPD) and patients with congestive heart failure (CHF). The risk of readmission was modeled using
logistic regression. Discriminatory ability was evaluated using receiver operatic curves and Cstatistics.
RESULTS
139,007 patients with 283,000 hospitalizations were included in the analyses. Mean age at
hospitalization was 67 and 66 years for men and women, respectively. In the model including all
patients, the strongest risk factor for readmission was having 5 or more unplanned admissions
during the year leading up to the index hospitalization (odds ratio [OR], 3.99; 95% confidence
interval [CI] 3.60–4.42). Having 3-4 or 1-2 unplanned admissions in the prior year also increased
readmission risks considerably, with ORs of 2.14 and 1.54, respectively. Among specific diagnoses,
advanced liver disease (OR 2.76; 95% CI 2.04-3.73) and kidney failure (OR, 1.73; 95% CI 1.57-1.91)
conferred the greatest risk increases. We also saw increased risks if the index hospitalization was
unplanned (OR, 1.71; 95% CI 1.64-1.77). The discriminatory ability of the model was satisfactory
with a C-statistic of 0.72 (95% CI, 0.71-0.72). Results in the sub-cohorts were similar to the main
model.
CONCLUSIONS
In this study, based entirely on electronically available data on all patients in the Stockholm County,
Sweden, we have developed a prediction model for unplanned readmissions. As in previous similar
studies, we see strong associations between the number of prior hospitalizations as well as
between a number of selected diagnoses and the risk of being readmitted. Overall, the final model
exhibited reasonable discriminatory ability, albeit with insufficient precision to permit pinpointing
of individual patients.
32

The data also demonstrate the feasibility of developing such a model based entirely on routinely
collected, administrative data, which would thence permit real-time prediction upon patient
discharge. In addition, our data might also provide useful insights concerning the day-to-day
management of patients with high risk of readmission. Coupled to a suitable intervention
designated to reduce risks of readmissions, we feel that a prediction model such as this one might
help reduce health care expenditures.
33

PLANNING FOR FUTURE HEALTH CARE IN STOCKHOLM
Birger Forsberg1 ,2, Kajsa Westling2, Håkan Lenhoff2, Yvonne Lettermark2
1 Karolinska Institutet, Stockholm, Sweden, 2 Stockholm County Council, Stockholm, Sweden
CONTEXT
Health care in Sweden has traditionally been delivered through a publicly financed system with
public service provision. In Stockholm region, where now more than 20% of the Swedish population
live, gradual change in services have taken place and a purchaser-provider model for management
of the health care system model has been adopted by the regional health authority, the Stockholm
County Council (SCC). With a rapidly growing population and a slightly overaged health care
structure a bold initiative has been taken to develop a grand plan for health services development
in the region.
METHODS
The method used in the development of the plan was participatory with a number of working
groups from all parts of the health care system and the purchaser function involved. The
participatory planning was supported by careful modelling of future health care needs and health
care development based on extensive analysis of available databases and technical expertise in the
county council administration and services management. All results and reports were eventually
compiled in a summary report with recommendations for action in the short- and long-term. The
plan was adopted by the politically elected council.
RESULTS
Health care needs will increase continuously over the study period due to increases in both
population size and in ageing. Non-communicable and chronic diseases will dominate the burden of
disease. Most of those cases are best managed in primary care. Still, large resources will continue
to be used by the patients with greatest needs. Even so, the need for in-patient services is
estimated to increase by 33% in 2030 compared to 2009. New investments should be made in
highly developed local health care. Specialist centres will be established at smaller community
hospitals where essentially all basic specialist care will be provided. Some specialist centres will also
provide inpatient services and basic emergency care. By this, the work burden of emergency
hospitals will be reduced. Highly specialized care will be concentrated to a new university hospital.
CONCLUSIONS
Preventive and health promoting services will be increasingly important at all levels of care to
guarantee equality, improve outcome of health services and limit costs of health care. New ways to
communicate with patients and the population have been reviewed and will be strengthened in the
coming years. The study concludes that the SCC must give priority to reducing health care needs
through various measures, such as accelerating health promotion and improving patient
information through e-health in particular.
34

Parallel Session:
Health Workforce: New World – New Roles?
Thursday 14 June 2012,
11.00-12.30
35

EMPLOYING NURSES IN ADVANCED ROLES IN PORTUGAL: EVIDENCE, ENABLERS AND
BARRIERS TO INNOVATION
Gilles Dussault1, Inês Fronteira1, Marta Temido1, Luis Lapão1, James Buchan2
1 Instituto de Higiene e Medicina Tropical, Lisbon, Portugal, 2 Queen Margaret University, Edinburgh, UK
CONTEXT
The utilization of nurses with expanded roles has grown significantly in various countries in Europe
and elsewhere in recent years. Arguments in favour of their use focus on cost -effectiveness, on
filling skills gaps, and on improving access to health care delivery in underserved service and
geographical areas. This paper presents empirical research examining the evidence base on nurses
practising informally in advanced roles in Portugal, and on drivers, enablers and barriers to formally
introducing nurses in advanced roles in the health services system.
METHODS
A multilingual literature search of published and grey literature has been conducted. The main
material comes from structured interviews with key stakeholders and policy makers nd from an
online survey of administrative and clinical managers at primary care level.
RESULTS
Data show that the issue of the expansion of the role of nurses in Portugal has only been discussed
for about 2-3 years, mainly at the initiative of the Nursing Council. No formal discussion with the
medical profession has taken place, as the Medical Council has repeatedly stated that this was not
opportune. The issue has been brought on the political agenda by the Ministry of health as part of
its strategies to improve the efficiency of health services. Interviews and responses to the
questionnaire indicate that individuals (physicians and nurses) are open to giving nurses more
advanced responsibilities, under certain conditions, namely, that their training is adapted and that
their professional responsibility is engaged.
CONCLUSIONS
Whereas the Nursing Council, until recently, was alone in supporting the idea of advanced roles in
nursing, it now has an important ally, the Ministry of Health (and in fact the government itself)
which sees this innovation as a strategy to improve the efficiency of services. The opposition of the
Medical Council is strong, though individual physicians are open to the idea, particularly in primary
health care services. It is difficult to forecast the evolution of this debate, but given the observed
trends in the rest of Europe, the context seems favourable for the adoption this innovation.
36

EXPLORING THE POTENTIAL OF E-HEALTH IN THE PROVISION OF INTEGRATED
PHARMACEUTICAL CARE SERVICES
João Gregório, Luís Lapão
Instituto de Higiene e Medicina Tropical, Lisboa, Portugal
CONTEXT
It is generally accepted that community pharmacies, and their professionals, could play an active
role in healthcare systems. Healthcare reforms on primary-care are starting to deal with the role of
community pharmacists. Due to easy accessibility and perceived affordability, pharmacists are the
first point of contact in the healthcare system in many developed and developing countries. It is of
importance for science and society to understand the role of community pharmacy services within
an integrated healthcare system and to research how e-health technologies could be developed and
used to address the challenges of economic and human resources crisis.
METHODS
Collection of data on pharmaceutical services and diagnosis of use of IT Technologies in Pharmacy
settings allowed the researchers to evaluate the economic and clinical value of Pharmacy Services to
patients. After this, and to study the patterns of Pharmacy Services provided, we selected a set of
pharmacies willing to participate in the study, in order to better analyze the pattern of services'
provision, supported by observational studies and socio networking analysis.
RESULTS
We have found significant evidence of pharmaceutical services value in the context of primary-care
chronic disease management, depending on several factors, such as the characteristics of the
patient, the relationship with the General Practitioner, relationship with the pharmacist, and the use
of e-health technologies. We found that although 97% of the pharmacies in Portugal use IT systems
for dispensing and administrative processes, the majority are not exploring any IT system to assist
pharmaceutical care provision. Also, we found that the provision of pharmaceutical care services is
sometimes confused with the provision of activities such as blood pressure or cholesterol
monitoring, with the lack of an IT system being one of the reasons for such misconceptions.
CONCLUSIONS
The understanding of future pharmaceutical services role in patient management within the primary
care setting is novel and critical to the extent that there is significant shortage of health
professionals within the primary-care setting. The application of these methods to improve patient
management (mostly chronic diseases) within healthcare services will be an important contribution
to science and is likely to be incorporated into actual Health systems in the future. The results of
this research are also likely to have an important impact on the quality and costs of healthcare by
further increasing the optimization of resources usage and the aptitude of existing information
management systems. With this data and results we will develop a prototype of an e-health
pharmaceutical service, using service management models (DEMO) and patient management theory.
37

PERFORMANCE ANALYSIS WITHIN CLINICAL DIRECTORATES: EVIDENCES FROM ITALIAN NHS
Americo Cicchetti, Daniele Mascia, Federica Morandi, Ilaria Piconi
Catholic University of Sacred Heart, Rome, Italy
CONTEXT
Clinical directorates represent semiautonomous hospital divisional units in which several clinical
wards are integrated, in order to pursue common care goals. During the 1990s, directorates were
introduced into the Italian NHS in order to improve quality of care. Many authors have investigated
the organizational model, but there are few evidences about the correlation between organizational
criteria used to design directorates and performance levels reached through such a model. The aim
of this study is to bridge this gap.
METHODS
We have been used two levels of data. A first set of data is about organizational features of clinical
directorates. These were gathered through a survey administered in collaboration with the Italian
Ministry of Health. We used a semi-structured questionnaire during on site visits within over 30
Italian health care organizations. Questionnaire items were related to three organizational criteria,
considered strategic for designing clinical governance oriented directorates. These are
Decentralization degree; Level of Integration; Level of Standardization. Each item contributes to
determining the score reached by departments. The second set of data, pertaining to the same 30
clinical directorates, regards performance levels. These data have been obtained from hospital
discharge forms that are made available by the Italian Ministry of Health. We have analyzed
performance through different perspectives such as clinical and organizational appropriateness of
care; quality of care and activity data. Moreover we have analyzed performance as employee
satisfaction.
RESULTS
Our preliminary results show the existence of a correlation between organizational features and
level of performance. In general we can observe that the higher scores the clinical directorates
achieve, the higher performance levels they reach. In general results show the existence of some
typologies of directorates able to show systematically better levels of performance. More in
particular we can observe a direct correlation between the criteria used to design clinical
directorates and the level of employee satisfaction. The perception of a substantial change has a
positive impact on the satisfaction of the physicians involved in the departmentalization process.
We can observe that the level of satisfaction of medical staff working in specialty directorates is
lower than that of the colleagues who work in departments organized by process. This evidence is
tightly connected with the criteria of the departmental organizational design process.
CONCLUSIONS
The National survey analyzed over 60 clinical directorates belonging to 30 Italian health care
organizations. The study correlates the criteria used during the departmentalisation process and
the level of performance reached by directorates. Results show a correlation between these
dimensions. Our original framework of analysis allows to examine contextually features, autonomy
and coordination within clinical directorates, and their impact on performance. We offer a
"snapshot" of the Italian healthcare organization in reference to the adoption of clinical directorates
and results in terms of appropriateness of care and employee satisfaction. The scores assigned by
our framework enable the Ministry of Health, General Managers and Clinical Directorate Managers
to identify the best practices, and therefore to imitate successful experiences in order to improve
the quality of care. Finally the correlation between organizational criteria and employee satisfaction
is useful to understand the point of view of physicians involved in departments‟ activity.
38

Parallel Session:
Patients’ Perspective
Thursday 14 June 2012,
11.00-12.30
39

INFORMAL HEALTH CARE PAYMENTS IN ROMANIA IN THE CONTEXT OF HEALTH SYSTEM
REFORM
Marius Ionut Ungureanu, Razvan Mircea Chereches, Ioana Andreea Rus, Cristian Marius Litan, Bianca Baciu
Center for Health Policy and Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-
Bolyai University, Cluj-Napoca, Romania
CONTEXT
Informal payments have been recognized as a long-lasting issue affecting the Romanian health care
system, but they have not been tackled consistently by any previous health reform process.
Previous research shows that the financial resources employed by people to offer these payments
are a threat to the access and equity principles of health care services delivery. Despite this, solid
documented information about the magnitude of informal payments, as well as people‟s
perceptions and attitudes are still lacking. This papers aims at providing key aspects about offering
informal health care payments, from the patients‟ perspective.
METHODS
A national representative sample of 1,500 individuals was interviewed by telephone, using a 5-part
questionnaire. The questionnaire collected general information about the study participants, the
health services accessed during the previous 12 months, whether they offered informal payments,
the types and value of informal payments offered and the attitudes towards them.
RESULTS
Of the total number of respondents, 47.4% were men, 57.8% were urban residents and 36.2% are
suffering of at least one chronic disease. 16.2% of the respondents declared to have offered
informal payments at their last visit in the doctor‟s office. 36.6% of these payments were in money.
54.9% of the participants in the study are against or totally against informal payments, whereas
61.4% believe that informal payments are an important or very important problem of the Romanian
health care system. Despite this, 44.2% believe that informal payments increase the quality of the
services provided by health care professionals. To reveal the determinants of informal payments, a
generalized linear regression with logit function was employed. The variables for which the model
yielded significant results were the residence area, ethnicity, attitudes towards informal payments
and age.
CONCLUSIONS
Informal health care payments are a widely spread phenomenon, as reported by users of health
services provided in the Romanian health sector. However, the percentage we report is lower than
the figures reported by countries with similar socio-economic profiles. The difference might be
attributed to respondents‟ tendency to offer socially desirable answers. Nonetheless, our results are
an indicator that informal payments need to be addressed by solid policies, in order to reduce their
negative effects both at an individual and system level. This aspect is especially important at this
stage, when Romania is preparing to reshape the organization of its health system, mainly
concerning the access of private insurers on the market.
This work was supported by CNCSIS-UEFISCSU, project number PN II-RU 319 /2010, contract no. 47/29.07.2010.
40

LONG TERM HEALTHCARE REFORM EFFECTS IN HEALTH PROFESSIONALS AND PATIENTS'
KNOWLEDGE AND ATTITUDES. A SOCIAL ANTHROPOLOGY PERSPECTIVE
Laia Bailo1, Tino Martí2, Antoni Peris2, Alba Brugués2
1 Universitat Rovira i Virgili, Tarragona, Spain, 2 CASAP, Castelldefels, Spain
CONTEXT
In the last three decades, the Spanish public healthcare system has evolved from a social health
insurance to a national health service. This transition has meant a huge development for primary
care practitioners that have widened and increased the service basket supply. Likewise, a devolution
process took place during the reform and this has brought autonomy to regions in healthcare
planning and organization.
METHODS
A 3 months observational field study was conducted by a social anthropologist to gather qualitative
data regarding knowledge and attitudes of patients and professionals towards public primary care
health services. Areas covered in the study include: (¡) analysis of financing, purchasing and
provision data, (ii) professional activity in clinical and managerial practice (iii) interprofessional and
interorganisation collaboration.
RESULTS
Despite the time past since the health system reform, patients still belief that they are covered by a
social health insurance scheme. Professional also appear to be strongly influenced by the former
system as professional lobbies have prioritized illness over health prevention and promotion as an
interlocked cause and consequence cycle with an increasing medicalised society. Difference in
knowledge and attitudes are observed among health centres and health professionals mainly
explained by age. However, a lack of awareness of the current health system functioning is
observed regardless of years of practice. From a patient perspective, there is also a
misunderstanding on the discretionary power of health professionals.
CONCLUSIONS
Healthcare reforms have long term effects in patients and professional attitudes and behaviours
and require a wide scope of analysis. Social anthropology brings useful methods to analyze levers
and barriers to healthcare improvement. Interprofessional primary care teams seem to be highly
resolutive and perform better under pay for performance schemes. Nevertheless a higher link with
community and social needs is to be developed to attain a better level of population problems
resolution in a less clinical way.
41

PRODUCING AND FUNDING FUTURE ELDERLY CARE SERVICES - DIFFERENT GENERATIONS'
PERSPECTIVES.
Minna Kaarakainen, Virva Hyttinen, Sanna Suomalainen, Sampsa Wulff
University of Eastern Finland, Kuopio, Finland
CONTEXT
This study focuses on the views of different generations on how they see these services would be
best organized and funded. The case country in this study is Finland, because Finnish welfare
services have faced an enormous economic crisis, and the future of public resources is more
limited. Tax-funded welfare states have been under pressure to re-organize both services and
funding. One given option is individual preparedness for service need and funding. The purpose of
this study is to take a look at the Finnish welfare state from the point of view of production and
funding of nursing services.
METHODS
The study was conducted as a two-fold study. First, we gathered focus group interviews from 30
citizens. We wanted to investigate what individuals think about a happy old age is like, and what is
good care and cure. After analyzing the results, we did a quantitative questionnaire based on them.
This research was conducted in May 2011 by an internet panel that consisted of 1011 citizens. The
group was representative by respondents' age, area, income and gender. Statistical methods were
used when analyzing the results, such as the analysis of variance (ANOVA), and multinomial logistic
regression model (MLRA).
RESULTS
In this paper, we examined the views of people of different ages over the matter of who should be
the instance responsible for providing nursing services, and how such services should be financed.
The results showed that younger people (between the ages of 18-34 and 35-54) are more willing to
take personal responsibility (such as personal insurances) for financing nursing services they need
in their senior years than those of their more senior counterparts (people aged 55-74). Other
affecting factors included variables such as income, education, and marital status.
CONCLUSIONS
In general, it can be said that the welfare state has a vast support among Finnish people. This
support includes extensive and high-quality social security as well as the significant role of the
public sector as a producer of welfare services. Citizens of Finland are even willing to pay more
taxes rather than approve cuts in the social security system.
42

THE INTEGRATION OF PATIENTS IN THE SERVICES PROCESSES ATTITUDES OF THE UPPER
AUSTRIAN POPULATION
Margit Raich, Daniela Deufert, Christoph Zulehner
University for Health Sciences, Medical Informatics and Technology, Hall, Tyrol, Austria
CONTEXT
The willingness for reforms is growing by the population. How critical and responsible clients
present their needs to the health care service providers remains to be seen. Because of the fact that
individuals are more and more confronted with the self-management concerning their health, they
will critical question the services rendered and the way how they can integrate themselves in the
system design. The aim of the study was to analyse the attitudes of the Upper Austrian population
concerning services rendered by the health care industry and how the people would participate on
the process of the services rendered.
METHODS
501 quantitative computer-assisted telephone interviews with random sample and quota control
were conducted. The data were analyzed using SPSS.
RESULTS
28% of the people believe that the sole responsibility for the health care provision lies with the
public authorities. Almost half of them (48%) ask for a solidarity-oriented division of responsibility.
They have the opinion that health care is rather a task to be fulfilled by the public authorities. But
they also think that the citizens should increasingly assume more responsibility. The people
questioned the design of the health care service offers. 89% hold the opinion that the one-day
clinical treatment is a good to good type of offer for little surgical interventions. Taboo topics
include the renunciation of the free choice of suppliers, such as GP, medical specialist or hospital
(91%), the renunciation of modern medicine according to the current state of research (88%) and
monetary contributions imposed on the individual in terms of medical practice fees (78%) or the
increase of the daily rates for in-house hospitalizations (76%).
CONCLUSIONS
In view of these results, when implementing system changes in the future, these aspects should
also be paid attention to in order to fulfil the citizens' expectations without collecting individual
financial contributions. This means, in concrete terms, calling for self-responsibility of the insured
by looking for possibilities of self-participation in the health care service provision instead of
imposing monetary contributions.
43

Thematic Parallel Session:
Integration
Thursday 14 June 2012,
16.00-17.30
44

INCREASING INTEGRATION OF HEALTHCARE SERVICES THROUGH NEW ORGANISATIONAL
FORMS: NETWORKS FOR MULTI-CHRONIC PATIENTS
Federica Segato, Martina Dal Molin, Cristina Masella
Politecnico di Milano, Milano, Italy
CONTEXT
Chronic diseases are the leading cause of deaths in medium and low-income Countries. These
illnesses cause premature death, frequent admissions to hospital, decrease quality of life, cause
loss of physical functioning and increase required medication, therefore determining a serious
impact on the patients‟ quality of life, on their need for health services and on total healthcare
expense. The inability of Healthcare Systems to assure them appropriate care is caused mainly by
scarce integration and coordination between providers. Accordingly, the quest for new
organisational paradigms aimed at making healthcare more integrated is overriding in researchers‟,
practitioners‟ and regulators‟ agenda.
METHODS
We employed multiple methods in our study to better clarify the rising models of integrated care for
multi-chronic patients (mainly network-like organisations), in order to uncover: 1) which are the
requisites for their effective implementation; 2) the readiness of the Italian context to undertake the
changes needed. We first performed an analysis of the main literature concerning factors driving to
the network formation (Grafton et al., 2011; Kickert et al., 1997), the enablers of network
functioning (Grandori and Soda, 1995) and the effect that the integrated forms of care delivery have
on the expected outcomes (i.e. higher quality, efficiency). Second, we accomplished a longitudinal
multiple-case research (Yin, 2003), aimed at analysing two paradigmatic Italian cases of care for
chronic patients. Last, to complete the information concerning the likelihood of change acceptance
in the Italian scenario, we prepared and submitted a survey to 637 GPs.
RESULTS
Once detected the drivers, enablers and outcomes of networks of care for multi-chronic patients
through the literature analysis, we examined two Italian cases. By collecting evidence from several
sources at multiple levels of analysis (semi-structured interviews, documents and archival records),
we tested the consistency of the theoretical framework and we evaluated the suitability of the
network-like forms of care for multi-chronic patients. The need for encouraging the role of primary
came out as a main result, despite the general lack of consensus among the GPs. To better
understand the reasons of the GPs‟ reluctance to take care of complex patients, we preliminarily
assessed their ability to cope with ICT tools (requested to make networks work), in order to
comprehend whether they represent a barrier against GPs‟ involvement. The results of the survey
showed that a large percentage of GPs already employs these systems or show interest in them.
CONCLUSIONS
Consensus is reached about the need for facing the complexity of multi-chronic patients through
primary care-centered integrated forms of care delivery. Nevertheless, the prerequisites for their
appropriate functioning are still unclear. Our study helps researchers, practitioners and regulators
in detecting the enablers and drivers of the integration, so that they can assess the promptness of
the actors playing in their contexts and the effort required to implement the changes needed.
Though we expect initial concern in the transition to the integrated form, we believe that patients
will benefit fast from the new form of care delivery in terms of improved quality (e.g. fewer
duplicated prescriptions, fewer accesses to the hospital, etc.). Further research is needed to assess
results in the medium-long term, to consider if additional factors may be responsible for achieving
better results and to further reinforce the framework, by applying it in other contests or other
experimentations.
45

SHEDDING A NETWORK LIGHT ON INTEGRATED CARE -A DIFFERENT (RE)VIEW ON
PERFORMANCE OF DEMENTIA CARE NETWORKS
Iris Saliterer, Sanja Korac
Alpen-Adria Universitaet Klagenfurt, Klagenfurt, Austria
CONTEXT
Throughout the world, new ways of healthcare delivery, achieving better coordination of services
are discussed, resulting in new models of integrated, shared care. Research in this field is mainly
theoretical; more rarely, one can find evaluations of the models. Thus from a management
perspective one main point, a performance framework, is missing. The aim of our paper is to
discuss network literature contributions and adapt them to the issue of integrated care assessment.
We shape a more application-oriented discussion by putting the theoretical discussion into the
context of dementia networks, representing one of the most complex types of healthcare delivery.
METHODS
We used an extensive literature review to search for groundwork about networks in health care and
in other policy fields and to identify performance measures used in network assessments. We had
to abandon the attempt to conduct a systematic review for both research questions, as the plurality
and diversity of terms used to refer to or describe „networks' (e.g. „partnerships', „alliances',
„collaboration'), and „performance' („effects', „benefits', „outcomes', hindered comprehensive
searches in the various literature databases. The review strategy therefore included the search for
the keywords and their synonyms used in literature without subject limitations. The results were
analyzed for their relevance to our context, followed by reviewing the bibliography used in the
articles matching the search. We made a synthesis of critical success factors, prerequisites, and
assessment fields discussed in network literature. Based on this, we framed evaluation fields for
dementia networks as one manifestation of integrated care.
RESULTS
In the literature, performance of integrated care often is evaluated by measuring the effectiveness
of each organization participating in the model or client-related outcomes. However, organizational
level and client outcomes are too short-sighted for the provision of health care, as they only reflect
how well particular components of the variety of services are delivered. We therefore examined
articles and findings in network research focusing on the whole of network, in order to provide
evaluation fields for the functionality of the dementia networks. We found Goal Consistency; Power
in terms of Comprehensiveness, Compatibility, and Accessibility; Trust and Information Sharing;
Complexity and Dynamics; and Policy (In-) dependency as the critical success factors and evaluation
fields for networks. By considering these fields on the one hand, the design of dementia networks
could be improved, and on the other hand they can form a starting point for the operationalisation
of future evaluations.
CONCLUSIONS
Our review showed numerous parallels of network theorists' and researchers' contributions to the
field of integrated care. We did not intend to build a framework for measuring the performance, but
for the assessment of success factors to use in the design phase of integrated care delivery as well
as in the evaluation of the network functioning. Our paper had to cope with barriers to a systematic
review and therefore has the limitation of somewhat subjective literature reviews, which can lead to
exclusion of maybe highly relevant articles. We tried to compensate this with the bibliography
review, which in turn can lead to a publication or self-reference bias. Our findings show great
importance and adaptability of network theories for integrated care. We offer implications to the
discussion of performance in dementia networks and thus hope to enrich the field of integrated
care by providing a network perspective rarely considered so far.
46

TRENDS OF MODELS IN HOSPITAL GOVERNANCE IN THE NETHERLANDS: FAILING
INTEGRATION OF MEDICAL SPECIALISTS IN HOSPITALS?
Linda Muijsers
Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
CONTEXT
In European hospitals, the relationship between professionals and management is often perceived
as problematic. In the Netherlands, several attempts are being made to find an appropriate
organizational model that facilitates the management of this relationship. The focus has been on
integration to achieve "unity of effort among the various subsystems in the accomplishment of the
organization's task" (Lawrence & Lorsch, 1967, p. 4). However, the degree and meaning of this
integration has been changing constantly. Currently the need for appropriate governance models
has never been more important of financial, demographic, and technological pressures and
increasing interference of the government.
METHODS
The tension between professionals and management in hospitals often has been perceived as a
power struggle (Scholten & Van der Grinten, 1998, 2002). In this article the hospital governance in
the Netherlands during the last five decades is studied from the power perspective. Questions are
asked about the power division, power characteristics, governance structure and why changes
occur. The article mainly focuses on the developments of hospital governance in the Netherlands
during the past six years (2005-2011), with reference to the historical background and especially
models which "expose the development in thinking" on hospital governance (Scholten & Van der
Grinten, 1998, p. 34). In describing the last decade this article aims to fill the knowledge gap in the
available literature, through continue the work of previous research (Juch, 1996; Kruijthof, 2005;
Putters, 2001; Schaaf, 2000; Scholten & Van der Grinten, 1998, 2002, 2005).
RESULTS
The preliminary analysis highlighted the development of various models and three developments in
hospital governance since the Second World War. Initially, hospital organization evolved from a
model consisting of two separate silos ("physicians hospital"), into an „integrated' model
("Management Participation"). Medical specialists have been formally and hierarchically integrated in
the hospital ("Integrated specialist company"). Subsequently, hospital organization changed from a
decentralized to a centralized organization ("Management Participation"). Currently, a new model of
hospital governance is emerging with a focus on decentralization and centralization.
Decentralization refers to the power shift towards (medical) managers at the unit-level with a focus
on medical, organizational, and financial themes (e.g. "doctor in the lead"; "Business Unit Model").
Centralization refers to the increasingly formalized legal final responsibility of the Board of
Directors and the expanding formal power of the Supervisory Board ("good governance"). Moreover,
other subgroups in the hospital are gaining power (f.e. clients, nursing).
CONCLUSIONS
These findings indicate that governance models have an effective lifetime of approximately 10
years. The power balance in hospitals (and related models) shifted along the continuums
centralization-decentralization and differentiation-integration. Currently the focus is on the
decentralization, the centralization and the expansion of power in the hospital. It can be stated that
the focus appears to be on disintegration (New Public Management). The focus of hospital
governance is on bureaucratic control rather than workable co-existence of various subgroups.
Current trends can also be explained by the decentralization-paradox which states that by shifting
power to lower level units, the Board of Directors increases the capability to govern the hospital.
47

Despite various initiatives to reduce tensions between actors in hospitals, especially management
and (medical) professionals, the attention for „integration', of doctors and management but also
cost and benefits (financially), over the past few decades had little added value for the
governmentability of hospitals.
48

DEVELOPING CLINICAL GOVERNANCE INNOVATIVE PRACTICES IN PRIMARY-CARE: SELF-
ORGANIZATION AND VERTICAL INTEGRATION DYNAMICS
Luis Velez Lapão, Claudia Leone
Institute of Hygiene and Tropical Medicine, Lisbon, Portugal
CONTEXT
The Portuguese Primary Care Reform presents the opportunity to explore and improve the
management models and practices, promoting quality and a patient-oriented service. The aim of
the present investigation is to study the evolution (since 2009) and the impact of the management
practices of the Group of Health Centres (ACES), focusing in the implementation of clinical
governance (CG) and its linkage with the secondary care. Furthermore, we will take the opportunity
to study this dynamics by exploring the existence of two different vertical integration settings:
ACES that are formally involved in Local Health Units (LHU) and those who aren‟t.
METHODS
In order to respond to the objective of the present study, a qualitative approach together with an
action research methodology were considered. After a literature review to allow a better
understanding of different CG experiences in selected countries, the process of data collection
started through the elaboration of 12 focus groups and questionnaires applications, which are
currently taking place around the Portuguese territory. The aspects considered in the sessions are
related to the ACES performance and self-organization dynamics of ACES regarding clinical
governance in both different vertical integration settings. The data collected is analysed in order to
diagnose the evolution of the different management models and to identify good management and
clinical governance practices, which show the benefits and opportunities of continuity of care.
Additionally, we will evaluate the impact and the cost effectiveness of two different management,
and CG models, which have been developed at both organisational care settings.
RESULTS
The methodological design of the present study aims to contribute towards a better knowledge and
performance of the current management models responsible for the development and execution of
clinical governance along the Portuguese health system. The results so far have shown several
patterns of innovative action towards the development of a CG culture: the creation of clinical
councils with the responsibility to tackle CG, the creation of expert groups to promote and share
best practices, etc. In addition, we have found out the emergence of complex behaviour among the
interactions between the different levels of services related with clinical governance. Regarding the
study of CG at two health care settings of vertical integrations, a better understanding of the
impact/cost effectiveness of health management and clinical governance was obtained: A SWOT
analysis on both setting will be presented.
CONCLUSIONS
In order to improve healthcare services from vertical integration (ACES formally involved in LHU),
one should considered two important conditions: a clinical governance model that enable the
alignment of activities between the primary and the secondary care; and the existence of an
Information Systems for registering and sharing clinical records that will allow an improved
management performance and CG decision-making. Both conditions were evaluated in the present
study. A better understanding of best fitted CG models, applied by the Group of Health Centres
while tackling quality improvements, is a critical matter. Therefore, it is of immense relevance to
understand how these models could be developed to strengthen the decision-making and the
capacity to manage the interface with secondary care.
49

Thematic Parallel Session:
Working Together
Thursday 14 June 2012,
16.00-17.30
50

HOSPITAL BOARDS AND MEDICAL SPECIALISTS COLLABORATING FOR QUALITY OF CARE
Daan Botje1, Thomas Plochg2, Niek Klazinga2, Cordula Wagner1
1 NIVEL, Netherlands institute for Health Services Research, Utrecht, The Netherlands, 2 Department of Social Medicine,
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
CONTEXT
In European countries policy briefs are stressing the importance of hospital governance for the
quality of care. When governing towards quality it is essential for Hospital Boards to receive the
proper information to do so. In the Netherlands, the national association for medical specialists has
provided suggestions about which information medical specialists should share with their Boards.
The aim of the present study was to identify to what extent the Hospital Board and medical
specialists focus on quality, and which sources of information are shared between them.
Additionally, we investigated to what extent they collaborate for quality of care.
METHODS
In our cross-sectional study in the Netherlands we sent questionnaires on governance and quality of
care to the Chief Executive Officers (CEOs) and Chief Medical Officers (CMOs) of all 97 hospitals
during winter 2010-2011. The self-reported questionnaires for CEOs and CMOs were fairly similar
and consisted of a validated translation of an American survey on quality (Jha and Epstein, 2010).
Questions were added to the questionnaire to identify compliance with sources of information to be
able to determine which sources of information were shared by medical specialists, and which
sources were used by the Hospital Board for policy-making. Additionally, CMOs could indicate in
which areas medical specialists engaged in governance.
RESULTS
Out of 97 hospitals 40 CEOs and 67 CMOs completed questionnaires. The Boards that spent more
time on quality during meetings scored higher on perceived expertise in quality management, were
more familiar with national quality programs, and attributed a higher score to the collaboration
between the Hospital Board and medical specialists. In hospitals having an information protocol,
more information was shared with the Board. The number of sources shared by medical specialists
and used for policy-making by the Board differed tremendously among hospitals. We also found
that the amount of sources was higher when the Board's quality orientation was high. Results
showed that medical specialists engaged with several areas of governance, for instance with
developing and implementing protocols or quality improvement projects. CEOs and CMOs
considered the collaboration between the Board and the medical specialists for the quality of care
to be good.
CONCLUSIONS
Current policies aim for quality orientation in hospital governance and information-sharing, but
thus few hospitals completely met the expectations. Although it is still unclear why compliance with
policy is shortcoming, we did find hospitals with both a high quality orientation and a high amount
of information being shared. Also engagement of medical specialists in governance can be
considered to be a prerequisite to govern a complex institution such as a hospital. Besides,
previous studies have shown that the hospital performance on quality of care benefits from a good
collaboration. Could it be that if CEOs consider quality to be important, medical specialists are
more likely to participate in quality too? In the Netherlands, both hospital remuneration system and
contracts with health insurance companies are increasingly depending on hospital performance on
quality indicators. Future research should focus on the relationship between governance and the
quality performance.
51

INFESTO - ANTI INFECTION POLICY
Juhani Pekkola
Kymenlaakso University of Applied Sciences, Kotka - Kouvola, Finland
CONTEXT
Infections prohibit recovery of patients, contaminate the personnel and lead to incapability to work.
Sometimes it is difficult to recruit staff for hospitals which are drastically contaminated. The costs
for patients, staff and especially for societies are enormous - not mentioning human suffering. The
problem is spreading.
Fighting the infections require new drugs. This takes a lot of time and effort and is expensive.
Anyhow the opportunities to prohibit infections are various. There are cost effective options to
develop products and working methods and address them in the chains of care in order to defeat
infections.
METHODS
In product design method for problem solving is co-operation with health care authorities and
professionals in order to identify places in care processes in which the prohibition of infections is
promising. Main areas are Hospital care, Home care and Transport. Action research identifies
challenges of daily work and generates solution for customers first using the methods of social
science and later on with the methods of natural sciences and work place development.
The Infesto-project organise a policy to investigate work practices empirically, via observations,
discussions and analyses. Working groups consisting of workers, professionals and students
analyse the challenges and generate basic solutions, which are send to technical analysis and
product design.
In principle the project analyse tacit knowledge among professionals and make it explicit. Coded
information is a source for product development and process innovations in health care. Product
development is done together with health care professionals, designer, researchers and industry.
RESULTS
There are hardly any product development for ambulances and home care despite of the need. The
consortium developed smart products which have the entity of anti-infection and fit for daily health
care. They are inexpensive to produce and easy to dispose. The blankets in ambulances are thick
and expensive. There are neither technical nor financial means to wash or replace them after every
patient. This leads to contamination of patients, staff and the vehicle. Ambulances carry infections
from hospital to the next one. The consortium developed and patented an inexpensive cover based
of material and product design. The cover is capable to carry a patient weighting 200 kg. The
patient can be carried to operation room with it and after use, the cover will be demolished. The
cover protects both the patient and the personnel from infections. The product has no alternative
on the market and it offers business opportunities.
CONCLUSIONS
Kymenlaakso University of Applied Sciences develops cost effective products for health care. The
amount of elderly people will increase, the dependency rate worsens, the personnel in health care
institutions retire and the shortage of health care professionals will increase. Our policy is to 1.
Identify cost effective solutions needed - in home based health care as well as on the area of
hospital care and patient transport - form the point of fighting infections. 2. Develop products with
anti-infection properties. 3. Co-operate with industry, government and research institutions and
generate a network for permanent co-operation.
52

DIFFERENT WORK VALUES AND AIMS OF SUBCULTURES - IMPACTS ON PATIENT CARE
Margit Raich
University for Health Sciences, Medical Informatics and Technology, Hall, Tyrol, Austria
CONTEXT
The analysis of the corporate culture gives information about the orientations and philosophies that
exist in an organization. Organizations also have many subcultures, systems with their own cultural
orientation, implicit values, norms and aims that result in different behaviours. If the value and
orientation patterns of subcultures are different, the question arises whether in the end a
successful cooperation can be ensured into regard on a common business goal. The presented case
study shows how different values and aims of occupational groups can influence negatively the
cooperation and the patient care in a hospital.
METHODS
The objective of the study is to identify - from a system level - the central values and aims of the
subcultures and to gather information to what extent they are responsible for conflicts in an
organization. In a second step the author is interested which kind of impacts do they have on the
quality of the patient care. 29 people from different structural levels of an Austrian hospital were
asked in form of open questions about the tasks of their departments, their individual activities and
the ways of cooperation. The texts were analyzed with the qualitative method GABEK. It is a tool to
analyze textual qualitative data and it is based on a theory of linguistic gestalten.
RESULTS
There exist a large number of people and groups who are primarily following their own interests
and trying to go their own ways. In this connection, many different values and aims exist in the
interaction, also different methods of debate and problem solving. The presented expert
organization is characterized by a three-way arrangement in workgroups: physicians, employees in
administration and care. Each workgroup marks itself through specific knowledge, norms, values
and behaviours. For example, in comparison to the physicians the nurses are defined as a group
with strong patient orientation. Physicians are more focused in a scientific career that is related with
a lack of time for patients in the day-to-day interaction. In addition, the administration staff is
characterized to improve their power by structural changes that hinder an effective treatment of the
patients.
CONCLUSIONS
The study points out the different ideas of occupational groups about the behaviour of colleagues,
executives, organizational regulations and competences. The presentation modus of the method
shows the connections of the various variables and allows developing effective measures for the
management to reduce conflicts around different values and aims of subcultures. For the staff in
the hospital exists a lack of a clear orientation. In this connection some objectives like vision and
strategy are named to diminish the disorientation of the staff. Finally, the author likes to propose
and discuss the possibilities to repair the existing broken relationships in order to improve the
situation for the staff and patients.
53

UNDERSTANDING BOARD GOVERNANCE AND PATIENT SAFETY: A PROGRAMME THEORY
PERSPECTIVE
Ross Millar, Tim Freeman, Russell Mannion
University of Birmingham, Birmingham, UK
CONTEXT
Over the past 10 years or so there has been an increasing recognition that the governing boards of
healthcare organisations should demonstrate more effective leadership in relation to their oversight
of quality and patient safety. Governing boards have traditionally tended to delegate the quality
oversight or have not considered quality as a top priority. However, as a result of recent scandals
particularly in the United Kingdom, efforts have sought to define good governance practices and
provide guidance for boards and chief executive officers (CEOs) for evaluating and improving
governance performance.
METHODS
The aim of our paper is to examine understandings of how healthcare boards govern patient safety
and, more specifically, how the patient safety benefits of corporate governance are derived. Using
the English National Health Service as a case study, it employs a „theory based' approach in line with
Pawson and Tilley's (1997) „Realistic Evaluation' to identify the underlying programme theories of
board governance and patient safety. To do so the paper draws on a review of literature and a
series of qualitative interviews in the English NHS with key informants that include healthcare
regulators, medical profession, and other NHS workforce representatives.
RESULTS
The paper finds that whilst the roles of leaders and boards of trustees are promoted as important,
understandings of how boards of trustees and senior health care leaders govern quality and safety
vary, and the mechanisms by which governance may lead to improved patient safety are less clearly
defined.
CONCLUSIONS
The paper considers the implications for future policy and practice in this area.
54

Thematic Parallel Session:
Operations Management
Thursday 14 June 2012,
16.00-18.00
55

HEALTH CARE REDESIGN: MANAGING A CHANGING HEALTH CARE ENVIRONMENT
Melissa De Regge1 ,2, Paul Gemmel1, Rik Verhaeghe1 ,2, Bart Sijnave1 ,2, Peter Degadt3, Philippe Duyck4
1 Ghent University, Ghent, Belgium, 2 Ghent University Hospital, Ghent, Belgium, 3 Zorgnet Vlaanderen, Brussel, Belgium,
4 AZ Nikolaas, Sint Niklaas, Belgium
CONTEXT
Hospitals are changing from functional and bureaucratic organizations towards process-oriented
service-line organizations. At the same time, management techniques originating from industrial
practices are diffusing throughout hospitals. This results in the awareness that there should be a
better fit between the customer needs and the service delivery processes in the future design of
hospital care, which requires a rethinking of the business models used by hospitals. Moreover, to
date, the majority of hospitals use one business model to treat patients with very different needs.
This „one-size-fits-all‟ model has been criticized and more „focused‟ delivery systems have been
proposed.
METHODS
A distinction is made between „solution shops‟, focusing on patients with a high degree of
uncertainty in the care delivery such as in the diagnostic stage, „value adding process business‟
(VAP), focusing on the efficient and safe treatment of patient paths with a limited amount of
uncertainty, and „facilitated networks‟ focusing on integrated care for chronically ill
patients[6](figure). Uncertainty, as reflected in the amount of variability in the patient delivery path,
seems to be an important variable of how to design a hospital delivery system which is more
focused to the needs of groups of patients. In this study we want to analyze whether structured and
unstructured care can be recognized in the care for a patient population of acute care hospitals
when looking at the length-of-stay (LOS) variability in the All Patient Refined Diagnosis Related
Groups (APR-DRG), and therefore observe if individual departments already apply a differentiated
approach to patient care.
RESULTS
Data were collected in two large Belgian hospitals from March 2009 until April 2011. All Patient
Refined Diagnosis Related Groups (APR-DRG) were used for analyses. These data were linked with
demographic data (gender, age), administrative data (date of admission, date of discharge, readmission)
and APR-DRG specific data ( Medical Diagnostic Categories (MDC), surgery or medicine,
charged number of admitted days, severity of illness and risk of mortality). Our analyses show that
the patient population of the two hospitals can, to some extent, be separated in different business
models (solution shops, VAPs and facilitated networks) by looking at the variability of LOS and the
level of severity of illness within APR-DRG categories.
CONCLUSIONS
It becomes clear that both hospitals do take into account the amount of uncertainty and variability
in the way they organize the care process (e.g. by different care coordination mechanisms), but are
not really designed around these differential patient needs. In other words structured and
unstructured care is delivered in the same departments with the same people, but in a differential
way. Most hospitals still deliver care using a one-size-fits-all model, thereby denying that
customers‟ needs can be different. Our study shows that, although hospitals are still organized
from the perspective of one single business model, individual departments already apply a
differentiated approach to patient care. Solution shops, VAPs and facilitated networks are present in
hospitals, albeit in an embryonic stage. This shows that health care workers acknowledge the need
for a differentiated approach and the change that has to be made is not as radical as one could
think.
56

PROCESSES' MAPPING IN HEALTH CENTERS
Silvina Santana, Patrícia Redondo
University of Aveiro, Aveiro, Portugal
CONTEXT
Under a logic of service integration, quality of care, in its several dimensions, depends not only on
how the internal processes are implemented but also on the quality of the transitions of care with
other entities and the management of the entire network. Therefore, it is fundamental to identify
and to understand intra- and inter-organizational processes and Petri nets might prove to be an
effective tool in this regard. The main objective of this work is to show how processes mapping may
contribute to the improvement of intra- and inter-organizational integration of care.
METHODS
We conducted a case study on a Health Centre (HC) located in the Centre Region of Portugal. Data
was collected during the first semester of 2009 through direct observation, documental analysis
and semi-structured interviews to relevant actors, namely, family doctors, nurses, social worker and
office worker. Petri nets were used as a modelling tool.
RESULTS
We have identified and mapped eleven processes involving a patient or other client directly. The
informality of many of the processes became evident. Activities are guided by formalisms imposed
by law and regulations and by the best practice of intervening professional groups; however, some
of the situations are not framed by these formalisms. Some processes are not standardized and
represented in the computerized information system and computer applications are not completely
integrated. Doctors and nurses work with different platforms, for which in some cases connections
have been developed. Communication with external entities is mostly made by phone, paper and
face-to-face. Within the RNCCI, information is organized in an integrated manner, and processes are
supported by a web-based national-wide information system. However, the RNCCI platform does not
integrate with the other health centre computerized applications and do not contains all relevant
patient data.
CONCLUSIONS
The case study has demonstrated the feasibility and the benefits of using process mapping
techniques in the context of an important entity in the Portuguese NHS, the Health Centre. In fact,
we have been able to: identify the WHAT, WHEN, WHERE, WHEN, WHO and the documentation
associated to each process, sub-process, task and activity; indentify and describe patient
transitions; identify and represent sub-processes (hierarchy) and routing (actual and possible); and
define and visually represent the actions, timings and waiting times, decisions and bottlenecks with
Petri nets. Moreover, the methodology has fostered brainstorming and enlarged discussion of
assumed, many times tacit knowledge and working practices.
57

QUALITY OF SERVICE AND QUALITY OF CONSUMABLES AND MEDICAL DEVICES: WHO PAYS
AND HOW THE DE- CENTRALIZED VS CENTRALIZED PROCUREMENT PROCESS CAN SUPPORT
PATIENT SAFETY?
Anastasia Balasopoulou1, Christos Mpoursanidis1 ,2
1 National School of Public Health, Athens, Greece, 2 National Centre for Public Administration, Athens, Greece
CONTEXT
The Quality of Services, directly related to Patient Safety, is a demanding issue. One of its aspects is
the Quality of the Consumables and Medical Devices used during the clinical procedures; it
contributes to better patient outcome and clinical quality or the opposite. It's not given, due to its
relation to both doctors' preferences and high cost. Does the supply system influence the quality of
the consumables and devices available for the clinical staff and if yes how? The degree of
centralization is one main change in these systems; what its impact could be? What about the
payment?
METHODS
The study focuses on the Greek case during the last 10 years. In this period several interventions of
the Procurement process, both legislation and organizational, created a continuously changing
environment, aiming to contain cost and reduce corruption. The government's main policy was to
make the system more centralized. The Quality criterion of supplies became weaker. The data used
is collected by Regional Authorities and Hospitals according to criteria which support the
comparability. It is organized to compare the aspects of cost (obvious and hidden), time consumed
and technology level of two distinguished categories, consumables and devices, to identify payment
flows.
RESULTS
It seems that the procurement and purchasing process, especially the centralization, does have a
strong impact on the quality of the resulted mix of the expensive consumables and devices
available for the clinical staff. The results of the study proved that the centralization was proved
poor in terms of cost containment and even poorer in terms of quality for the case of the finally
purchased consumables. The results give evidence that this impact (of the centralisation) was not
that strong for the case of the purchased devices, but the study identifies a trend for less quality.
The hospitals' autonomy and accountability on this critical issue do not exist, since the
responsibility supposed to be undertaken by central bodies, in which hospital and insurance funds
are excluded. But who pays? The Social Insurance Funds, i.e. the Insured citizens, and the State
continue to pay, either without been aware or ignoring this negative change.
CONCLUSIONS
Within the given economic circumstances, possible for more European countries apart of Greece,
the quality of the hospital supplies must be guaranteed. Thus the procurement and purchasing
processes must be enhanced by criteria as well as regulations' setting; these have to be supported
by organizational systems and mechanisms in order to be introduced as critical priorities. The
centralization is impossible to be accepted as the main intervention in the system, while the
accountability of the involved parties is getting lost in the bureaucracy. The criterion of quality must
be the first, while containing the cost and the role of both hospitals and payers must be revised in
order to improve and guarantee the patient safety.
58

OPERATIONAL ACCESS TO LONG-TERM CARE FOR ELDERLY: FINDINGS FROM A CASE STUDY IN
THE NETHERLANDS
Lisette Schipper1 ,2, Bert Meijboom1, Katrien Luijkx1, Jos Schols3 , 4
1 Department of Tranzo, Tilburg University, Tilburg, The Netherlands, 2 Surplus, Zevenbergen, The Netherlands, 3 Caphri,
Department of General Practice, Maastricht, The Netherlands, 4 Department of Health Services Research, Maastricht,
The Netherlands
CONTEXT
Clients are increasingly demanding about the health care services they require. This challenges
health care providers to offer a demand-based and integrated supply of services. In addition,
market elements have been introduced in the health care sector in the Netherlands. To distinguish
themselves from competitors and to be able to arrange individualized service packages for clients,
a well-organized and designed service entrance process is a primary prerequisite. Currently, Dutch
long-term care providers are reconsidering the operational access to their services in order to raise
productivity and to meet the demands of their clients more quickly and accurately.
METHODS
We studied literature on access to care to discover relevant aspects of operational access. In access
processes direct interaction with clients is often required. We therefore combined insights on
operational design of customer contact (front/back office and task (de)coupling) into a framework
with the dimensions availability, affordability and acceptability of access to care services. This
framework underlies the execution of this multiple case study to analyze existing operational
access processes. Purposive sampling was used for case selection to ensure comparability on
relevant case characteristics, while warranting variation on others. The four cases selected are all
large, regional players in long-term care for elderly. The dimensions of our conceptual framework
were used to draw up a topic list, used for semi-structured interviews and observations of the
access processes. Furthermore, organizational documents were analyzed to facilitate triangulation.
All cases were described in detail and compared according to the dimensions of the framework.
RESULTS
The entrance processes were not arranged uniformly across the cases. It appeared that the
organization of the entrance facilities evolved over time rather than primarily being based on
operations design principles. By organizing separate entrance units, all cases opted to decouple the
access process from the delivery of care and services. They then chose to couple most entrance
related activities into one job. All four entrance units focused on first contact by phone or digitally.
Two organizations enhanced the availability of their entrance services by decentralizing their access
units. Affordability did not seem to be a relevant aspect. Specific service concepts on access were
hardly developed and client satisfaction is not measured on a structural basis yet. However, the
case organizations do invest in building relationships with their clients. Employees allocated to
front offices were relatively highly educated, based on competences needed for direct contact.
CONCLUSIONS
Assessing the care and service entrance processes through the framework facilitates systematic
comparison of all cases. It also shows that the combined theoretical concepts, both from a
customer contact perspective as well as from the multidimensional approach of access, can be used
to analyze operational access processes. All dimensions in the framework were confirmed in this
case study related to long-term care organizations. Moreover, the four cases provided insight in the
operational access process in long-term care facilities. A well-organized care and service entrance
process gives organizations the opportunity to distinguish themselves from competitors in
arranging individualized, tailor made services. Insights provided by the framework might help longterm
care organizations to organize their entrance unit in order to receive, clarify and fulfil the
requirements of their elder clients effectively as well as efficiently.
59

SELECTION AND WEIGHTING OF PERFORMANCE INDICATORS IN A PRIVATE HEALTHCARE
ORGANIZATION: THE BALANCED SCORECARD AS A TOOL TO SUPPORT MANAGEMENT.
Lara Santos, Denise Santos
UAL, Lisbon, Portugal
CONTEXT
To achieve clinical and financial goals, health policies and strategies have to be effectively
implemented, monitored, evaluated and periodically corrected, thus avoiding waste. Public or
private health organizations should be able to access their performance according to the defined
strategies, through a control management model, incorporating the various key performance
indicators (KPI) and their weighting. The objective performance evaluation gives feedback to
decision makers to define the initiatives that lead to performance improvement, increased
efficiency, and better clinical outcomes, according to the resources available. The objective of this
investigation is to build a customized tool to support management.
METHODS
The model is developed from the conceptual model Balanced Scorecard. KPI and their weights are
selected and calculated through a multivariate statistical analysis (Statistical Package for the Social
Sciences software) of a questionnaire presented by e-mail, with total confidentiality guarantee, to
collect the opinion of experienced managers in health sector about KPI, using a Likert scale (1 to
5). The Indicators present in the questionnaire were previously reviewed by a group of health
managers, and the questionnaire was validated by an expert, pretest, and its reliability assessed by
Cronbach´s alpha coefficient. The sample is non-probabilistic, for convenience, and snowball,
consisting of several managers of a major private health organization in Portugal, with different
health units, such as hospitals, outpatient clinics and long term care facilities. To characterize the
units and managers a descriptive statistical analysis is used.
RESULTS
This investigation considered that the selection and weighting of KPI influences the evaluation
(performance and strategy implementation), and the management tools have to be empirically
developed, in order to contribute to a model of management and evaluation of healthcare
organizations. As a result we will have a custom template, contextualized, and based on empirical
evidence resulting from the triangulation of the Balanced Scorecard with other currents of thought,
such as the European Foundation for Quality Management Business and Benchmarking. Until the
end of February we will be gathering data. However, preliminary results point to a greater
appreciation of the financial perspective (outcomes) in assessing organizational performance, and
productivity indicators (outputs) considered the most critical for management, management
control, and monitoring the strategy Implementation.
CONCLUSIONS
The performance evaluation of health organizations in Portugal, done traditionally by budget
control, productivity, cost control, and national health indicators, without cause-effect analysis, and
systematic economic evaluations, has been insufficient to achieve global health objectives. In
health, although there is a significant difference between public and private sector in terms of
financing, management frameworks, and strategy, both sectors have been adopting isolated
management tools, which did not allow, until now, an integrated and globally needed response for
the complex issues of the health organizations. The management tools will only be really useful if
they allow an integrated, objective and global evaluation, with comparison between performances.
The management model that results from this investigation, could be adapted to an interactive
software, to facilitate the measurement and evaluation of organizational performance, in a way
simultaneously customized and globally integrated, rendering more objective the decision-making
process.
60

THE APPLICATION OF LOGICAL FRAMEWORK TECHNIQUE AS QUALITY MANAGEMENT TOOL
ACROSS DIVERSE SETTINGS IN A TERTIARY CARE HOSPITAL IN MALTA
Sandra C. Buttigieg1 ,2, Prasanta Dey2
1 University of Malta, Msida, Malta, 2 Aston Business School, Birmingham, UK
CONTEXT
This paper portrays the diverse use of logical framework analysis (LFA) across multi-dimensional
settings in tertiary care hospitals for managing quality and improving patient safety. This
technique is a straightforward application that, with minimal resources, can effectively improve
patient care.
METHODS
Using LFA as a project-planning matrix, this study evaluates current state by identifying problems
and suggesting solutions in diverse settings, namely intensive care, coronary intensive care, general
surgery, and psychiatry. Additionally, it provides an integrated framework that spells out the
roadmap for holistically achieving targets.
RESULTS
LFA can be applied flexibly across hospital-based services. This study shows improvement in
management and staff satisfaction ratings using LFA in a few services in Maltese hospital.
CONCLUSIONS
This paper shows LFA application in specific, albeit, diverse settings in one hospital. For validation
purposes, it would be better to analyse other settings within the same hospital, as well as in several
hospitals. It also adopts a bottom-up approach when this can be triangulated with other sources of
data. LFA enables top management to obtain an integrated view of performance. It also provides a
basis for further quantitative research on quality management. Although logical framework has
been used by developing countries in mega projects to acquire funds from development banks, its
application in quality improvement projects is scant. LFA provides project-approving authorities
with in-depth knowledge, rationale, objective targets, verification of achievements, and
uncertainties that may not allow the project to achieve intended outcomes. Hence, it helps decisionmaking
in project planning, implementation and control.
61

PhD Students’ Session
Friday 15 June 2012,
11.00-12.30
62

STRATEGIZING IN A MESSY CONTEXT. A STUDY OF ACADEMIC MEDICAL CENTERS.
Adriana Allocato
Università 'Magna Graecia', Italy, Università di Napoli 'Federico II', Napoli, Italy, Aston University, Birmingham, UK
CONTEXT
Recently, Italian Academic-medical-centres have adopted private sector „managerialism' in response
to institutional pressures, declining state funding, and increased competition. Under these
conditions, managers have greater responsibility for collective strategic action. However, despite
the rise of managerial authority and responsibility, clinicians, as professional knowledge workers,
retain power and autonomy, so must have their views recognized in the strategy and management
of the organization. Tensions over strategic direction typically arise between the managerial values
of administrators and the professional values of clinicians. Exploring the strategy formulation
process, this research investigates how the coexistence of multiple cultures is channelled in
strategizing in AMCs.
METHODS
Drawing on a longitudinal, interpretative single case study of an Italian AMC, multiple data sources
were collected. Direct observation had been conducted at management meetings, at lunches and
listening to informal conversations before and after formal strategic meetings to catch the decision
process in practice. In-depth interviews encouraged participants to explain observed routines and
articulate underpinning logics or tacit norms of appropriateness. They were useful to understand
how multiple individuals viewed emerging issues. Finally documentary evidences provided
unobtrusive data for triangulation. Inspired by an inductive theory building logic, data analysis was
structured in three phases. First, reading the data, a three-dimensional model was created to
analyze the nature of the social interactions. Second, this model was integrated with empirical
interpretations to identify the role of the individuals according to what and how they were trying to
communicate. Finally, the social roles were compared and similarities between them explored.
RESULTS
The three-dimensional model about the nature of social interactions - persuasive, collaborative, and
directive - allowed the identification of four different categories of actors: drivers, shock-therapists,
saboteurs and quiet enthusiasts. Leaning on a shared assessment of the current strategic plan as
problematic and imbued by indecision, each of them use both quantitative tools and discursive
practices to support his interests and to impose power relationships and social order within the
organization. The findings suggest that how and why actors enact power is shaped by especially
three interrelated processes: channelling their interests through formal intentions and vision,
channelling their interests through informal interactions and channelling their interests through
symbolic embodiment in the strategic everyday work. Overall, the strategy formulation is
reconceptualised as a process stemming from the recursivity and the continuity of day-to-day
individuals' interactions and in which the meaning attributed to these interactions increasingly
converges within a final agreed plan.
CONCLUSIONS
The purpose of this study is to contribute to the understanding of strategizing, with a focus on the
social interactions between top managers and clinicians in this process in AMCs. While strategymaking
research was dominated by a rational approach that identifies the strategy as a set of
planned activities, empirical studies have demonstrated that strategy is also the outcome of an
intuitive and political behaviour. However, little is known about the actual practices that led to the
formulation of strategy and who are the actors involved in this process. This lack is also reflected
within the strategy-as-practice perspective, which calls for studies that illuminate the microactivities
involved in the social accomplishment of strategy. The dissertation responds to this gap in
the literature. Moreover it contributes to the practice-orientated demands. The close connection
between clinicians and their involvement in management and operations can be a source of
strategic advantage in AMCs.
63

PUBLIC HEALTHCARE ORGANIZATIONS: WHO REALLY DRIVES THE CHANGE?
Ekaterini Fameli, Erik Soderquist
Athens University of Economics and Business, Athens, Greece
CONTEXT
Based on the case of Greek Public Hospitals (PH) undergoing radical change during the
implementation of a new integrated healthcare operational system, this PhD research explores a
holistic framework for the unfolding of planned change, building on the four change „motors'
proposed by Van de Ven & Poole (1995). The aim is to advance our understanding of why change
unfolds as it does in PH and what are the factors that affect the success or failure of reaching the
planned outcomes. A holistic understanding of the way external and internal factors influence and
interplay during the change effort is proposed.
METHODS
The study builds on previous research from diverse fields in an attempt to shed light on the critical
determinants of change management in public hospitals. A quantitative analysis was used to
uncover causal relations and significant factors affecting the unfolding of the change. A
questionnaire survey was distributed in all the GPH that had undergone the planned change effort,
in order to test the hypotheses generated from the literature review. Confirmatory Factor Analysis
was performed as a first step to assess the proposed measurement model. We collected 210
questionnaires from hospital personnel that participated in the planning and implementation of the
change. Respondents represent all clinical and administrative staff categories. Structured interviews
with change agents were also conducted to enhance understanding of contextual variables.
RESULTS
Teleological factors such as managerial cognitions, leadership style, and goal-formulation influence
repetitively the progression of the change effort and serve as trigging mechanism for re-launching
the change if and when it loses momentum. The healthcare management principles and the aim for
change collide with bureaucratic tradition and resistance, leading to delays and adjustment of initial
plans. Such dialectical factors influence the change effort punctually during the unfolding, when the
antithesis of change accumulates enough quantity of colliding forces to produce a conflict with the
thesis in use. The thesis-antithesis-synthesis pattern cannot be completely developed in public
hospitals and the dialectic forces act merely as blockages than as drivers of change. Operation
under a bureaucratic structure, resulting from the specific lifecycle and evolutionary factors acting
on the change, might reduce uncertainty and provide structure, but also create inertia that is
inversely related to achieving the intended positive outcomes.
CONCLUSIONS
The timely and successful achievement of a planned change effort in public health organisations
depends on the presence and complementary interplay of the four change motors. The change
effort is strongly marked by life-cycle mechanisms as rules, codes and network system related to
the functioning of the PH. Teleological forces surfaced in the shape of actions for implementing and
controlling the achievement of goals. A variety of actions were planned and executed leading to the
emergence of dialectical processes in the intersection between purposeful action and life cycle
related rules, programs and habits. Our research provides new insights on the play and interplay of
different ‘motors' of change (Van de Ven & Poole, 1995) and the importance of managing them consciously.
64

DEVELOPING INTEGRATED CARE. TOWARDS A DEVELOPMENT MODEL FOR INTEGRATED CARE
Mirella Minkman
Vilans, National Center of Excellence in long term care, Utrecht, The Netherlands
CONTEXT
Integrated care is seen as a useful concept for improving the quality of care and lives of many
patients and reducing fragmentation and inefficiency in health care. Implementation of integrated
care is however complex and in the large range of possible activities it is often not clear what
essential activities are to implement at what time. It is therefore surprising that a generic quality
management model for integrated care that can facilitate implementation is lacking. In the thesis
seven studies are described which result in the Development Model for Integrated Care (DMIC).
METHODS
Two multiple case studies of 31 cases in dementia and stroke care which focus on the
implementation of integrated care are conducted. Secondly, a systematic literature review for the
evidence on improved performance by using existing quality management models was executed.
Next, based on a literature study, a three round Delphi study and a Concept Mapping study 89
essential elements of integrated care were identified and clustered in nine clusters. Based on an
expert panel study and a survey study the development of integrated care over time was
researched. The results came together in the DMIC. To conclude, the DMIC was empirically
validated in 84 integrated care services for stroke, dementia and acute myocardial infarct patients
by using a survey study with integrated care coordinators.
RESULTS
The DMIC described nine clusters containing in total 89 elements that contribute to the integration
of care. The clusters are: „client-centeredness', „delivery system', „performance management',
„quality of care', „result-focused learning', „interprofessional teamwork', „roles and tasks',
„commitment', and „transparent entrepreneurship'. Multiple aspects influence the dynamics and
development of integrated care services over time, but overall these processes can be
conceptualized as phase-wise growth. Four phases were identified: „the initiative and design phase',
„the experimental and execution phase', the expansion and monitoring phase' and the
„consolidation and transformation phase'. The empirical validation of the DMIC confirmed our
model: the elements are widely recognized in practice, the cluster relevance scores are all very high.
Despite differences in client groups, size, focus, and providers ranging from acute to long-term
social and mental health care, our study confirms that there are generic components which are
important for the improvement and development of integrated care services.
CONCLUSIONS
Improving integrated care is a complex topic in a large number of countries. A quality management
model like the DMIC can facilitate implementation by assessing the current situation and selecting
improvement activities that fit the phase of development. Surprisingly, only one third of the
coordinators self assessed the same phase of development as calculated by the model. It can be
assumed that the DMIC can be used for multiple types of integrated care services. The model has a
resemblance to existing quality management models like the CCM and the EFQM model, but has a
wider focus on effective collaboration, commitment, learning, roles and tasks and entrepreneurship.
The DMIC can be used by integrated care coordinators, professionals and managers to (self) assess
the current situation and guide improvement to further development phases. Policy-makers and
financers can use the DMIC to stimulate and reward further improvement in integrated care.
65

FRAMING AND RE-FRAMING CALAMITIES IN HOSPITALS: HOW DIFFERENT VIEWS ON
CALAMITIES SHIFT RESPONSIBILITIES FROM PROFESSIONALS TOWARDS MANAGERS
Lonneke Behr, Kor Grit, Roland Bal, Paul Robben
Erasmus University Rotterdam, Rotterdam, The Netherlands
CONTEXT
This work focuses on analyzing existing inquiries after calamities in hospitals. The framing of the
calamity often leads to a specific scope of actors, consequences and ways to allocate
responsibilities for medical error. In connection between the shift in risk perception and with
increased attention for patient safety, a change in managerial and professional responsibilities can
be observed. The role of inquiries can be identified as one of giving meaning to a calamity.
Although quality of care and patient safety are seen as primary responsibilities of professionals,
accountability is increasingly assigned to hospital management and governmental supervisory
organizations.
METHODS
We use qualitative methods to describe the role and significance of inquiries after a calamity took
place. Literature research and analyzing policy documents are part of the process identifying
the frames being used by involved actors who have done the inquiries. We selected three case
studies in Dutch hospitals which occurred in the last decade. The cases are selected on the bases of
the involvement of both internal and external committees of inquiry and the fact that all calamities
got a respectable amount of media attention. The examined cases refer to both material failure and
human actions that produce unintended consequences or even fatal results. Calamities are
identified, following the definition of the Health Care Inspectorate, as situations that involve
structural problems which can cause serious damage to general health care or individual patients.
The death of patients due to mistakes or unaccountable circumstances is also described as a
calamity.
RESULTS
By identifying different inquiries after a calamity took place, several actors can be distinguished. In
the selected cases the internal inquiries were carried out by the hospitals themselves and the
external inquiries were executed by the Health Care Inspectorate and independent committees like
the Dutch Safety Board. Document analysis shows increased (public) attention for patient safety and
expanding emphasis on managerial responsibilities. Although inquiries after calamities highlight
the need for health care professionals to complete the realization of their working standards, the
management of the hospital is hold accountable for all non-medical preconditions. We observed
that the Health Care Inspectorate is often blamed by the public media to have failed in their
supervision and enforcement of legislation. Involved actors addressing the calamity in a specific
frame, contribute to the rationality of risk, but also cause a shift in the allocation of responsibilities
from the professional level towards the managerial level.
CONCLUSIONS
Through our research of inquiries after a calamity took place, we theorize that the frames being
used by the involved actors play an important role in the outcome of the inquiry. Even as most of
the recommended measures are related to professional actions and direct behaviour of medical
professionals, the inquiries are framed on the managerial level, pointing towards the
responsibilities of the board of directors and the management of the hospital. Compared to former
inquiries an important shift in attention and allocating responsibilities can be observed. In the
recent political climate, were the government is no longer taking the lead, other actors are being
expected to develop and expand their role concerning the elaboration and implementation for
patient safety and good quality of care. Reframing calamities in hospitals within the policy process
has important consequences for the role of managers in health care.
66

Directive on the Application of Patients’ rights in Cross-
Border Healthcare: Outcomes of a Simulation
Friday 15 June 2012,
11.00-12.30
67

EU CROSS-BORDER HEALTH CARE SURVEY 2010 - PATIENT SATISFACTION, QUALITY,
INFORMATION AND POTENTIAL
Caroline Wagner1, Katharina Dobrick1, Frank Verheyen1
1 Scientific Institute of TK for Benefit and Efficiency in Health Care (WINEG), Hamburg, Germany
CONTEXT
The new EU Directive of 2011 includes the strengthening of patients' rights as well as a simplified
utilisation of EU cross-border treatments - along with the use of electronic data interchange. All EU
citizens thus have the right to choose their doctors across all EU member states which German
patients have already been granted by law since 2004. This was the reason for WINEG to investigate
the insurants' experience and needs with regard to EU cross-border treatments and the future
potential. The results provide valuable information for the further development of the range of both
services and benefits for insurants.
METHODS
Based on the former surveys 2008 and 2009, questionnaires were developed for the partial surveys
1 and 2 of the EU Cross-Border Care Surveys 2010. To allow chronologic comparison, essential
issues were again investigated (e.g. number and type of treatment, EU member state of treatment).
A new focus included questions on patient satisfaction with quality and other aspects of EU crossborder
treatment as well as on the need for information and on the willingness for repetition. The
questionnaire of partial survey 1 for insurants with treatment in EU member states in 2009 includes
42 questions and was sent to a randomised selection of 40,000 insurants by mail. The
questionnaire of partial survey 2 includes 30 questions and was sent to a randomised sample of
10,000 insurants without treatment in EU member states in 2009 in order to predict the future
demand. In a pretest, both questionnaires were examined on comprehensibility.
RESULTS
13,287 and 2,736 questionnaires, respectively, were returned. This corresponds to response rates
of 33 % and 27 %, which reflect the major interest in this subject. The main results are the still
distinct increase in planned EU cross- border treatments and the considerable patient satisfaction
above average. The latter is also reflected in the high willingness to repeat planned EU cross-border
treatment and the low rate of after-treatments. The willingness of insurants without experience in
EU treatments to ever receive treatment in EU member states is clearly lower. The future potential
nonetheless amounts to 30 % of all TK insurants. The increase in freedom of choice concerning
medical practitioners and treatments is crucial to insurants without cross-border care experience.
Quality has clearly priority over costs in this group of insurants in contrast to the insurants with
experience. The EU Directive is still equally unknown to both groups of insurants.
CONCLUSIONS
Treatments in other EU member states have already become an attractive alternative for many TK
insurants to treatment in the German health care system, concerning spa treatments, remedies,
general practitioner and preventive treatments. Those insurants willing to have EU cross border
treatments in future have clearly different needs. They seek for freedom of choice and quality while
cost saving is subordinate. This would lead to the development of a completely different group of
EU cross border patients in Germany. An increase in knowledge of entitlement and other patients'
rights in cross-border treatments is to be expected after the implementation of the EU Directive into
national law in all EU member states by 2013. The number of cross-border benefits to be financed
and administrative processes to deal with will rise. Statutory health insurance funds will adjust to
this development to provide their insurants the best support in this still new field.
68

Parallel Sessions:
Sustainable Financing
Friday 15 June 2012,
11.00-12.30
69

HOW TO GET MAXIMUM REIMBURSEMENT
Anne-Marie Yazbeck1, Primož Lukšič2, Alen Orbanid2, Jernej Bodlaj2, Katja Grašič2
1 National Institute of Public Health, Ljubljana, Slovenia, 2 University of Primorska, Koper, Slovenia
CONTEXT
Upcoding and miscoding is no novelty in diagnosis related groups (DRG) systems around the world.
The Slovenian health care professionals in acute settings have been challenged in various ways.
Patterns of upcoding and miscoding have been noted. The aim of this research project was to find
out in which cases health care professionals have a greater motivation to upcode DRGs and what
the main culprits for miscoding are.
METHODS
On the basis of DRG data between 2004 and 2009 the obvious patterns for the 3 most common
upcoded DRGs and the 3 most common miscoded DRGs were identified. Methods for upcoding
included practical work in the hospitals, questionnaires from which we evaluated possible reasons
for miscoding, statistical analysis (linear and multivariate regression analysis) and data mining.
Analysis was performed using different data mining tools: Weka, R, MatLab and SPSS.
RESULTS
Patterns of upcoding were detected in maternity wards, where extensive amount of cases of babies
with jaundice was detected (>40%). Miscodings of DRGs were identified in the Oncology wards in
two hospitals where patients going through chemotherapy were wrongly classified as hospitalized
(99% of the patients).
CONCLUSIONS
Upcoding and miscoding represent anomalies in all current Slovenian DRG systems. However, with
appropriate methods we can tackle the problem and substantially lower its consequences. With
regular analysis and feedback loops to hospitals miscoding and upcoding can be contained and
limited.
70

USE OF PATIENT LEVEL COSTING DATA TO ESTABLISH VALUE-BASED PUBLIC HEALTHCARE IN
ENGLAND
Mahmood Adil1 ,2, Naomi Chambers1 ,2
1 Department of Health, London, UK, 2 Manchester Business School, Manchester, UK
CONTEXT
The public healthcare system (NHS) in England is going through major policy changes, including the
development of new payer organisations (Clinical Commissioning Groups) and a greater range of
healthcare providers. This is to achieve high quality low cost (value-based) healthcare to meet the
needs of its population, at a time when NHS is facing £20 billion budget gap. Patient level costing
data is fundamental to develop clear understandings of resource utilisation and outcomes
(quality/variation of services) for the mutual benefits of payers and providers. It also helps to build
effective partnerships between clinicians and finance managers to establish value-based healthcare.
METHODS
Despite national policy to encourage all acute healthcare providers (trusts) to collect systematic and
reliable patient-level costing data, not many trusts in the country have been able to implement and
use Patient Level Information & Costing Systems (PLICS) effectively. We therefore decided to;
- Establish the current state of PLICS implementation in the NHS
- Explore the views of clinicians and finance managers about its potentially achievable benefits,
and issues related to implementation
- Identify examples of best practice where PLICS have helped to deliver value-based healthcare
services.
We conducted three surveys to gather the required information from acute hospital trusts in
England;
- Survey 1: Questionnaire sent to 167 acute trusts to establish the level of implementation
(implemented/implementing/plan to implement)
- Survey 2: on-line survey of Director of Finance of acute trusts
- Survey 3: on-line survey of lead clinicians from the acute trusts
RESULTS
The results helped to understand the current state of implementation and develop pragmatic
knowledge of the uses of PLICS by analysing the clinicians and finance managers responses;
Key findings:
- Response rate = 92%
- 68% have implemented or implementing PLICS
Main benefits:
- Cost improvement through enhanced technical efficiency
- Understanding clinical variation in resource use and the relationships between cost and quality
- Greater clinical engagement through more clinical ownership of costs and information systems
- Evidence-based performance reporting & benchmarking
Barriers/Issues in using PLICS data:
- Insufficient awareness across the organisation
71

- Poor presentation of financial data
- Lack of basic finance skills among clinicians
- Lack of formal mechanisms of joint working between clinicians and finance managers
Examples of best practice:
- 12 examples of best practice were identified, where both payers and providers used PLICS data
to improve quality and efficiency together
CONCLUSIONS
The conference theme has highlighted the importance of financial challenges faced by European
healthcare systems. Insights into patient level costing and related outcomes can provide
opportunities to develop value-based public health care systems in Europe. PLICS is a relatively
recent innovation in the NHS. It is a method of recording all significant activities that happen to
individual patient from the time of admission until the time of discharge and calculate the resources
consumed by using actual costs incurred by the organisation. Our research on PLICS has identified
benefits, barriers and pragmatic use of patient level costing data. It provides ideas to deal with
European healthcare management challenges, through joint efforts of payer and provider
organisations. A further study has now been commissioned by Department of Health in England
starting in 2012 to identify the potential of PLICS for whole health economies.
72

POSSIBILITIES FOR SUSTAINABLE FINANCING OF THE ESTONIAN SOCIAL INSURANCE SYSTEM
Ain Aaviksoo1, Priit Kruus1, Lauri Leppik2, Riina Sikkut1, Vootele Veldre1, Andres Võrk1
1 Praxis Centre for Policy Studies, Tallinn, Estonia, 2 Tallinn University, Tallinn, Estonia
CONTEXT
Estonian health insurance system is financed from labour taxes and is thus largely dependent on
the number and level of income of contributors. So far the system has been considered as one of
the most cost-effective. In the situation of aging population, dependency ratio is increasing and
thus affecting the sustainability of the system. To prepare future policies the government of Estonia
commissioned a comprehensive study to assess the long-term financial and social sustainability of
the whole social security system of the country and elaborate possible policy implications.
METHODS
Altogether 55 alternatives were analysed in a systematic manner for a list of impact criteria using
quantitative and qualitative methodology. As the basic task for the study prescribed inclusion of the
whole social insurance system, the choice of policy options to be included required an
unambiguously accepted procedure. All policy alternatives were first categorized based on the
possible extent of the change: a parametric change of current practice (1); a structural change
within mainly public financing (2); a reform involving private insurance (3). Also a base scenario,
which assumed no changes in the system, was developed. Criteria that all the alternatives were
analysed for were financial and social sustainability, impact on economy, impact on behaviour,
adjustability to external risks, technical feasibility. Analysis used a combination of desk-research of
international evidence, quantitative prognostic modelling and a 3-round Delphi survey with major
stakeholders of the social security system.
RESULTS
As far as the financial sustainability of health insurance is concerned, a budget deficit can be
expected. Income and spending are balanced in short term, but deficit will start to grow from 2030
onwards. Possible impacts of 18 different policy alternatives addressing the sustainability of health
system were analysed. All can be aggregated to 4 broad alternatives: increasing income by raising
taxes or broadening the tax base (1); cutting costs by making the system more efficient (2); cutting
cost by increasing individual responsibility with implementing private health insurance or medical
savings accounts (3); strengthening other social insurance schemes (4). As the income of the health
system currently depends highly on labour taxes, options with the aim of increasing employment
are significant and thus unemployment insurance, disability insurance and pension systems'
incentives play an important role in increasing the sustainability of health system - either reducing
expenses or increasing revenues.
CONCLUSIONS
The study is not a typical problem-solution research, rather an impact analysis of a broad range of
policy alternatives. It's an important landmark showing that a broader picture of the system is
needed, when discussing health care policy and financing reforms and whether to accompany
private insurance. There is no perfect, financially and socially sustainable system of social and
health insurance - the context and historical implications play an important part. The final
assessment of the system's functioning, its goals and necessary changes is subjective and strongly
dependent on value judgments, e.g. on attitudes towards solidarity and individual responsibility
and which goals the social security system should achieve. Therefore, the study does not give final
"good-bad" assessments or a value-based "top list", but describes potential impacts of policy
alternatives considering the whole context. Based on the report the government has initiated a
series of policy discussions for designing reform plans.
73

Parallel Sessions:
New Providers, New Models of Care
Friday 15 June 2012,
11.00-12.30
74

PLURALISM IN HEALTHCARE COMMISSIONING: PATTERNS OF DESTABLISATION IN THE
ENGLISH NHS.
Rod Sheaff1, Nigel Charles1, Naomi Chambers2, Ann Mahon2, Sue LLewellyn2, Russell Mannion3, Mark Exworthy4,
Richard Byng5
1 University of Plymouth, Plymouth, Devon, UK, 2 Manchester Business School, Manchester, UK, 3 HSMC, University of
Birmingham, Birmingham, UK, 4 Royal Holloway, University of London, Egham, Surrey, UK, 5 Peninsula College of Medicine
and Dentistry, Plymouth, Devon, UK
CONTEXT
Pluralistic commissioning is long-established in Bismarckian health systems. English NHS hospitals
are commissioned mainly by geographically based-organisations but with substantial
commissioning by general practices alongside. Primary care is funded mainly through a national
contract but a growing minority of private providers now have locally-negotiated contracts. Now
commissioning is being devolved to Clinical Commissioning Groups (CCGs) of general practices and
c.50 sub-regional organisations. CCGs are diverse. Many obtain commissioning support from
private organisations. We report what new configurations of commissioning organisation are
emerging locally, how far they reflect past commissioning patterns and seem associated with
different policy outcomes (e.g. budget compliance).
METHODS
1. Cross-sectional analysis of published administrative data from 2010 and earlier years,
supplemented with data sets obtained by Freedom of Information enquiries (unpublished data
which public bodies supply on request) and from professional organisations. Analyses are:
A. Tests of association on data on the organisational character and history of local health
economies (e.g. in terms of history of organisational instability, provider fragmentation) to
examine whether distinct categories of local health economy have emerged;
B. Tests of association between these categories and policy outcomes for tracer groups;
C. Refinement of (B) with controls for gross confounders (e.g. providers' managerial record, local
populations' age/sex and economic profiles).
2. Organisational case studies in four main study sites and for four main tracer groups (elderly
people at risk of unplanned hospital admission; planned orthopaedic admissions; mental
health; public health).
RESULTS
Provisionally (analysis continues) the following main patterns for organising and managing
commissioning appear to be emerging: (1) CCGs subcontract much of the management of
commissioning to commercial firms (consultancies etc.); (2) CCGs create or sub-contract a not-forprofit
social enterprise to do much of their commissioning management; (3) CCGs call upon public
organisations, i.e. the successors of PCTs, for commissioning management support (4) CCGs which
proceed more independently. These patterns do not (so far) appear to reflect the configuration of
local secondary providers, in particular the extent to which these providers are also becoming
pluralistic, nor the locality's epidemiological, geographical or socio-economic character. Micropolitical
relationships between general practices, between commissioners and hospitals, and
between commissioners and general practices appear to have been more influential in producing a
plurality of structures and modes of commissioning.
CONCLUSIONS
75

What data NHS bodies collate and publish constrains the scope of these cross sectional analyses.
More data on policy outcomes and provider performance have become publicly available but data
about local NHS organisational characteristics remain fragmentary, especially for public health
activity. The organisation of NHS commissioning remains unstable and likely to continue changing.
The emerging pluralism of commissioners and providers contrasts with the continuing
centralisation of NHS performance management. Many Bismarckian health systems, however,
combine national requirements for access to care and standards of care with pluralism of
commissioners and of providers. Our findings suggest that through the diversification of
commissioning organisations the English NHS may also be moving slowly in that direction. The
distinction, customary in Europe, between pluralistic Bismarckian and non-pluralistic Beveridge
systems may therefore require re-thinking in the near future.
76

PUBLIC-PRIVATE-PARTNERSHIPS IN HEALTH PROMOTION: EXPERIENCES, OPPORTUNITIES
AND READINESS IN SWITZERLAND
Michael Kirschner
Health Promotion Switzerland, Berne, Switzerland
CONTEXT
Public-private partnerships (PPPs) in public healthcare are still rare in Switzerland. However, the first
healthcare-sector projects that might be suitable for PPPs are starting to emerge. There have not as
yet been any PPP projects in the healthcare sector at federal level, where scope is restricted because
responsibility for most healthcare projects lies with the cantons. In the field of health promotion
and prevention, the private sector is strongly disapproving any legal regulations. Nevertheless,
experiences in workplace health promotion show that companies of all sizes and from all sectors
are ready to engage in PPPs. Is public healthcare ready too?
METHODS
Health Promotion Switzerland was actively seeking public-private partnerships for its key strategic
areas through dialogue and debate making use of its legal mandate to "initiate, coordinated and
evaluate activities to promote health and prevent disease". Established by the Federal Health
Insurance Act, the foundation brings together Swiss health insurers, cantons and other important
stakeholders. This openness made it possible that leading Swiss companies contacted the
foundation regarding the development of a common Swiss standard for workplace health
management (Friendly Work Space). Also, PPPs became the basis of a successful pilot project on
stress prevention in large Swiss enterprises (SWiNG) and for the development of an online stress
survey instrument for small, medium and large companies (S-Tool). Each time, the development and
implementation of standards and tools had to be negotiated between experts and practitioners
from public health, sciences and private businesses.
RESULTS
Today, more that 100'000 people work in Swiss companies (total of 3.5 Mio persons employed in
private businesses) holding the label Friendly Work Space - upward trend! Hundreds of Swiss and
other European companies are interested in S-Tool, an online stress survey instrument freely
accessible for companies. Leading Swiss companies with a combined total of over 5'000 employees
participated in the groundbreaking stress prevention project SWiNG which delivered instruments
and documentation for medium and large enterprises.
Through PPPs, Health Promotion Switzerland gained access to new fields of action such as
developing standards for workplace health promotion or stress prevention in private businesses.
Both sides, public and private partners generated cash, support and resources. Within different
PPPs, information, knowledge and expertise were openly shared. Product research and development
aimed at improving health. Finally, Health Promotion Switzerland was able to enhance health
promotion's image among typically sceptical / hostile constituencies.
CONCLUSIONS
Legal initiatives and policy papers in healthcare systematically emphasize the involvement of the
private sector and the importance of PPPs. In practice, there seems to be a gap between policy
papers and implementation. While public health actors often consider "sharing responsibility under
state control" or "to ease the pressure on budgets and improve efficiency" as goals of PPPs, the
private sector seems to have another understanding. In Switzerland, the private sector was invited
to participate in formal consultations processes for a new law on prevention and health promotion.
Criticizing its exclusion from working groups preparing visions, goals and the draft of the new law,
the private sector completely disapproved the law before it was even drafted. In the field of
workplace health promotion, the private sector opposes any legal regulation. Given these
circumstances and considering our experiences, PPPs need to be based on trust, dialogue and
mutual learning experiences.
77

NON-PROFIT PROVIDERS IN STOCKHOLM COUNTY COUNCIL – OBSTACLES TO ENTERING THE
HEALTHCARE MARKET
Kajsa Westling1, Ida Nyström1, Birger Forsberg2
1 Stockholm County Council, Stockholm, Sweden, 2 Karolinska Institute, Stockholm, Sweden
CONTEXT
In Sweden healthcare has traditionally been provided by public providers. However, in later years
political decisions in Stockholm County Council has created a more pluralistic healthcare market in
a purchaser-provider model where the purchaser has contracts with both public and private
providers. In an international comparison Sweden stands out as having few non-profit providers of
healthcare services. A project has been initiated in Stockholm in which advantages and
disadvantages with non-profit providers of healthcare are examined. Obstacles to entering the
healthcare market are identified and the project seeks to specify how those obstacles can be
reduced.
METHODS
Literature reviews and key informant interviews.
RESULTS
The study has found that it is important to encourage non-profit organizations to enter the
healthcare market as they generally are driven by clear values that are compatible with the overall
goals of service delivery as defined by the political system. A significant obstacle identified is the
legislation and regulation of procurement procedures that prevent non-profit actors with limited
financial strength to compete for contracts on the same terms as for-profit healthcare providers.
The study has identified that healthcare services produced by non-profit providers often stem from
patient organization or organizations working close to patients, for example treatment of alcohol-
and drug abuse, rehabilitation and psychiatry. It is also concluded that administrative arrangements
that can stimulate non-profit value-driven organizations to try new ideas for healthcare provision
within their agreements with the purchaser should be sought.
CONCLUSIONS
In the face of the many challenges presented to contemporary healthcare systems it is argued that a
pluralistic delivery model for healthcare services is to be preferred. The political leadership in
Stockholm County Council believes that pluralism of healthcare providers should increase
competition and productivity in the delivery of healthcare services but also increase the quality and
the value that is created for the growing diversified needs of patients. However, for a country like
Sweden that is in the process of health system transformation, with an increasing growth of nonpublic
providers, the structure, incentives and reimbursement systems of its healthcare system
needs to be adjusted to the differing needs of both profit and non-profit providers. This would
require a review of legislation of public purchasing at national level and at regional and local level
new ways of building partnerships between purchasers and profit and non-profit providers.
78

CAN HEALTH CARE SYSTEM BE ABLE TO PERSONALISE ITS SERVICE?
Mathias Waelli1, Etienne Minvielle2
1 EHESP, Paris, France, 2 CNRS/CERMES 3, Paris, France
CONTEXT
Addressing issues related to customization in the health care system refers to "Personalised care", a
word used in the biology area. However, this "biological driven" approach doesn't encompass all the
aspects of the quality of the service. "Personalised service" corresponds to all actions which fits
expectations during the process of care that each patient experienced. The concept of "patientcentered
care" brings information for capturing these different aspects. Nevertheless, the
customization of a service applied to the process of care asks for another question: how to take
into account the singularity of each process under constraints of resources?
METHODS
The aim of this research is to develop an integrated and theoretical model of "personalised service”.
The methodology is two-fold:
- A literature review. First, our review includes all French and English-language articles in the peerreviewed
literature (2000-2011) using the following terms: "personalised medicine", "patientcentered
care" and "personalised service". We searched 2 bibliographic databases (Pub Med,
Embase). Second, we reviewed different articles in management science (mainly, production
management).
- A case study in two Frenchs hospitals which lead initiatives in the area of personalised service
(2011-2012). One is a comprehensive care centre (Institut Gustave Roussy) and the other one
is a teaching hospital (Cochin, Assistance Publique-Hôpitaux de Paris). The data collection is
composed of participative observation (90 hours by hospital) and semi-structured individual
interviews of key-actors (N=21).
RESULTS
Our "personalised service” model is composed of 6 components: the first two are related to a
design process, the third, fourth and fifth ones are related to the work organization, and the last
one is related to the assessment phase.
- Design 1: Categorisations „system design (The way to identify sub-populations of patients with
common needs)
- Design 2: Health care organisation„s design (The way to develop a trajectory-line approach, e.g.
the emergence of case-managers)
- Work organization 1: The Role of Technology Information for improving the self-management
and the continuity of care
- Work organization 2: The human skills of service
- Work organization 3: The development of a co-produced service (e.g. shared decision making)
- Assessment 1: Taking into account the personal's experience of patient for improving the cycle
Patients needs/improvements
CONCLUSIONS
Beyond its intrinsic qualities, the diffusion of such a model depends on two key-factors: the ability
to apply an appropriated business model (the return on investments for hospitals), and the way to
implement different organizational improvements in the specific medical context of health care
organizations. It is also interesting to consider the specific target of personalised service in health
care compared to other sectors.
79

Many other sectors have experienced mass customization, customer experience or operation„s
management during the last decade (e.g. hotel industry, aeronautic, or cars' industry). In
comparison, all these experiences shared the following issue: the ability to customize every steps of
the process. It is unlikely to consider that all aspects of each patient can be personalised (as
customers in other sectors). And perhaps than more than "mass customization", the objective is to
understand how to combine "mass" and "customization".
80

Parallel Sessions:
Involving Citizens
Friday 15 June 2012,
11.00-12.30
81

ENGAGING PATIENTS IN THE COMMISSIONING OF CHRONIC PAIN SERVICES: A MODEL FOR
EFFECTIVE PATIENT AND PUBLIC INVOLVEMENT
Elaine McNichol
University of Leeds, Leeds, UK
CONTEXT
Patient and Public Involvement (PPI) in the provision and delivery of healthcare, particularly in
relation to chronic conditions (World Health Organisation 2006, Staniszewska et al 2011) is a
central, yet challenging area (Campbell et al 2011) for healthcare. It is grounded in the belief that
„patients understand the day to day realities of their conditions and the constraints of a limited
financial budget for healthcare. This paper will present and discuss the process for recruiting a
group of patients to participate in the commissioning of chronic pain services in a large U.K. city
and the impact of that process.
METHODS
Participants were recruited through an open letter to all patients attending the city's chronic pain
services. Adopting a process of co-production, five people with lived expertise of chronic pain
formed a Patient Community to work with the commissioning team. The methodology was
designed to facilitate dialogue between all stakeholders in the commissioning team (patients,
clinicians and non clinicians across primary and secondary care services) that was grounded in an
acknowledgement of the value of the lived experience and expertise of the patient as being
different but equally valid to that of the professional. The approach was constructed around three
core activities:
- An investment of time that takes the patients through a structured programme of development
to prepare them for articulating and sharing their experience
- Preparation of professionals for working effectively with patients
- Creation of a „resourced' Patient community to support sustained and meaningful engagement
RESULTS
Identifying the „impact' of PPI is recognised as „complex and multi-faceted' (Mockford et al 2012)
which reflect the outcomes of this study. This paper will discuss impact in relation to:
- The experience of participating patients
- * Sense of empowerment through the formation of the Patient Community, sharing
their experience and influencing the decision making
- * Knowledge and understanding of healthcare commissioning processes
- * Experience of working alongside clinical staff in a commissioning environment
- The experience of staff members (both clinical and non clinical) of the Commissioning Group
- The commissioning process
- * Richness of the discussion
- * Conduct of meetings
- The key features of the structured approach to PPI (Patient learning Journey and supported
Patient Community) and the transferability of the process of patient involvement to other
healthcare settings
82

CONCLUSIONS
Effective and meaningful PPI that is beneficial to the individual as well healthcare organisations is a
global issue (Campbell et al 2011). The approach described in this paper is built upon the principles
of:
- Mutual respect between patients and clinicians and commissioners for their respective lived
and professional expertise
- That the patient should benefit from the collaborative working relationship
These principles underpin the rational for using a process of co-production and the subsequent key
features of the structured approach to PPI that has been developed. An area for discussion and
further development is the transferability to other healthcare settings of the structured approach to
PPI that has been adopted, particularly in relation to other long term health conditions and the
education of healthcare professionals.
83

A PARADIGM SHIFT IN GOVERNANCE OF LOCAL CARE AND SOCIAL SERVICE IN THE
NETHERLANDS: FROM CENTRAL PROVISION TO LOCAL PARTICIPATION
Kim Putters, Maarten Janssen
Institute of Health Policy & Management (Erasmus University), Rotterdam, The Netherlands
CONTEXT
The enactment of the Social Support Act in the Netherlands in 2007 symbolized a major welfare
state reform. In addition to a decentralization concerning local care and social service, it intended
to cause a paradigm shift in local care provision. The new „compensation principle' describes a
replacement of citizens' rights on care by an obligation for municipalities to compensate citizens
for their barriers to participate. This paper analyzes to what extent this paradigm shift is realized
and what new governance arrangements were created.
METHODS
This research was conducted because of a cooperation agreement between the French Mission
Recherché (DREES) and the Erasmus University. Case studies delivered insights into the
consequences of the Dutch social support act, with the aim to deliver data for international
comparisons. A multidisciplinary research strategy was chosen with six case studies at different
municipalities. Desk research and interviews with key persons on the local- (civil servants) and the
national level (representatives of the Ministry of Health) were conducted. In this paper the cases
were analyzed according to three themes: citizen participation, tendering and governance type. In
line with the initial aim of the study international literature was used to compare the results with
other European contexts.
RESULTS
The social support act was intended to let people participate in society by compensating them for
their mental or physical limitations. The results illustrate the difficulties of putting this act into
practice by clarifying which judicial, organizational and care related issues come into play, e.g. the
organization of intakes and the tendering process. It is clarified how the paradigm shift causes the
creation of a variety of approaches within the municipalities with respect to the right to care, the
right to participate, the values of governance and the choice of local policy instruments. In addition,
some general developments, including the downscaling of initial ambitions and contradictory
movements of recentralization, are explained in detail. The analysis is conducted according to
international literature which provides some insights about the meaning of the results compared to
other contexts. This also allows for new international comparative research.
CONCLUSIONS
The radical nature of the paradigm shift causes uncertainty and ambiguity about the successes and
legitimacy of the decentralization. A paradigm shift will not be achieved by decentralization alone;
it requires a shift in local processes as well. Therefore, conclusions about the success need to be
based on specific local data. In this paper six cases are compared according to three themes:
citizen participation, tendering and governance type. For example, it is shown how policy
participation and the use of personal budgets are incorporated within social policy. Similarly, the
paper explains how the other themes work out in practice on different levels and according to
different instruments. New research would facilitate more profound observations about the
sustainability of realized changes. It would be very interesting to do an international comparison by
analysing cases from other European countries in addition to the institutional literature used in this
paper.
84

BRING A FRIEND - A PEER EDUCATION PROGRAM FOR CERVICAL CANCER SCREENING
AMONG IMMIGRANTS
Malena Lau1, Erik Olsson2 ,3, Mia Westlund4, Eva Runå-Ljungberg5, Bodil Frey6
1 Angereds Local Hospital, Gothenburg, Region of Västra Götaland, Sweden, 2 Division of Quality Sciences, Chalmers
University of Technology, Gothenburg, Region of Västra Götaland, Sweden, 3 Centre for Equality in Health Care,
Gothenburg, Region of Västra Götaland, Sweden, 4 Regional Cancer Centre, Westen Sweden Health Care Region, Sweden,
5 Antenatal clinic, Angered, Primary health care, Gothenburg, Region of Västra Götaland, Sweden, 6 Födelsehuset,
Gothenburg, Sweden
CONTEXT
Early detection of cervical changes through gynaecological screening serves as a good protection
against cervical cancer. In the region of Västra Götaland about 80 percent of women aged between
23-60 years take the Papanicolau (Pap) test within the cervical cancer-screening program. In
northeast Gothenburg 50 percent of the residents are foreign born and in this area only around 60
percent of the females are taking the test. This is a sign of inequality in health care that lead to an
increased risk of cervical cancer among these women.
METHODS
The "Bring a Friend" project was launched in April 2011 with the focus on spreading verbal
information between women about the importance of taking the test. In the northeast part of
Gothenburg a number of "doulas" are already a well established group of women, primarily
supporting new parents during pregnancy and childbirth. The doulas are well integrated women
with the same cultural background as the parents they support. Information about the screening
and about cervical cancer was given to them by midwives and the information was then spread
through their social networks. Other information channels were through local associations, local
radio stations and at public places. Leaflets and information folders were produced and translated
into a number of languages. During the project a modified bus was used as a mobile unit that made
it possible to take the Pap smear test at strategically located places in the area.
RESULTS
Between April and November of 2011 a total of 3891 tests had been taken, which is an increase
with 56 percent compared with the same period the previous year. A survey showed that more than
one third of the women who took the test in the bus had never had it taken before. Healthcare
professionals in the area also noticed that groups of women that were known of not taking the Pap
smear test now showed up to take the test at the primary care. The bus also had another health
preventive effect since many women used the chance to ask the midwives other health related
questions and took the opportunity to write their own referrals to the gynaecology clinic.
CONCLUSIONS
Lack of knowledge about why the test should be taken, an inability to assimilate information in
Swedish and no previous experience to seek preventive care are reasons many women stated for
not taking the test previously. To be able to receive information by a woman that you trust, who
share your cultural background and mother tough has been crucial for the success of this project.
Another key factor is the cooperation within the project between health organizations, NGO's, the
civil society and academia. The cooperation has also created good conditions for further spread of
the results to the rest of the region and the country. The project will be finished in April 2012.
85

Poster Sessions
Thursday 14 June 2012 Friday 15 June 2012,
15.30-16.00 13.30-14.00
86

CEOS' CAREER PATTERNS IN HEALTHCARE: EVIDENCES FROM THE ITALIAN NATIONAL HEALTH
SERVICE
Daniele Mascia, Ilaria Piconi, Americo Cicchetti
Catholic University of the Sacred Heart, Rome, Italy
CONTEXT
In many Western countries a few number of reforms during „90 have called for strategic and
managerial reorientation of health care organizations. In this backdrop, the creation of a Chief
Executive Officer (CEO) position appears to be particularly salient because of its influence on
strategic decision making within organizations. Although extant research widely acknowledges that
CEOs' career does matter for strategic decision-making and organizational performance, there is
scant knowledge on health care CEOs' career patterns.
METHODS
We collected data on careers of Italian health care CEOs in 2008. Our sample is made of 124
healthcare CEOs, corresponding to 41% of all the healthcare CEOs in service in the I-NHS. The data
on career paths were collected based on CEOs' biographies. With an approach similar to Fahey and
Mirtle (2001), we coded patterns of job change in two ways: traditional career path and single or
multiple career path. In the first, the career of executives is mainly developed in the healthcare
industry. Single or multiple career paths characterize those CEOs who, during their career histories,
entered and then left the health care sector. Secondary data were also collected on a number of
individual characteristics (gender, tenure, seniority, etc.), as well as other organizational
demographics (dimension, case index, etc.). Correlation analyses were performed to test statistical
association between selected variables.
RESULTS
The mean age of CEOs in our sample is 55 years old. Female CEOs constitute only 12% of the
sample. Roughly half (52%) of the CEOs have a background in medicine. Top managers' average
tenure in the I-NHS is fifteen years. Out of the sample, 75% of CEOs have performed a traditional
career path whereas 25% of them were characterized by single or multiple career paths. Prior
experience outside the health care boundaries was gained in the tourism, automotive and public
utilities sectors. Significant differences for CEOs having a traditional career and those characterized
by single or multiple career paths were observed with respect to a number of individual attributes.
CONCLUSIONS
The role that executives play in health care organizations is continuously increasing. Upper
echelons literature has widely documented that individual characteristics of CEOs have a major role
in explaining decision making, strategies and ultimately performance within hospitals. Careers path
seems to loom particularly large in this context because it is through experience learning that
executives acquire important knowledge and competence that they use as leaders of complex
organizations. In spite of this importance, there is a dearth of studies on this particular issue. Our
findings document that, in the Italian NHS, CEOs exhibit various career paths and that these are in
turn related to different individual demographics. These results provide a number of relevant
practical implications for policy makers.
87

INVESTIGATING THE ORGANIZATIONAL IMPACT OF THE INTRODUCTION OF NEW ORAL
ANTICOAGULANT THERAPIES (OATS)
Americo Cicchetti1, Federico Spandonaro2, Vincenzo Aparo3, Matteo Ruggeri1, Maria Letizia Mancusi2, Silvia Coretti1,
Paola Codella1
1 Università Cattolica del Sacro Cuore, Roma, Italy, 2 Università di Roma Tor Vergata, Roma, Italy, 3 Istituto dermopatico
dell'Immacolata, Roma, Italy
CONTEXT
In 2009, the RE-LY trial proved the effectiveness, safety and compliance of Dabigatran, a new oral
anticoagulant therapy, which does not require continuous monitoring of anticoagulation, avoiding
periodic blood tests. Currently, in Italy, Cumadin is considered as the gold standard for the
management of atrial fibrillation. Specialized centres are now involved in the care and monitoring of
clinical conditions of the patients undergoing OAT. The aim of this study is to collect the opinions
of clinicians about the organizational changes required by the forthcoming introduction of new
OATs in the Italian clinical practice.
METHODS
We administered a frontal interview to the directors of five OAT centres set in four Italian Regions,
selected in order to represent the complexity of the Italian scenario. The questionnaire is composed
by two parts. The first one, called "Current organizational structures" investigates the current centre
features, the number and kind of human resources dealing with OAT patients, the level of
complexity, the affiliation to a network of structures. The second part of the interview focuses on
the opinions of physicians about the organizational changes which could occur after the
introduction of new OATs in the clinical practice. The latter includes items concerning challenges in
working activities, effects on patients' Qol and their management, needs of professionals' training,
cooperation and communication instances. The answers given are summarized in tables.
RESULTS
According to the interviewees, a re-modulation of the centre routine will be required by the coming
of Dabigatran in the market: OAT centres will dedicate more work to the consulting activity instead
of monitoring of patients. For patients, a sensible improvement in quality of life is expected; only
one interviewee considers the reduction of controls a possible threat to patients‟ compliance. All
the participants agree about the necessity of establishing training activities to guarantee an
appropriate prescription of the new drugs and to allow an adequate management of complications.
The most important investments are expected in the field of coordination and communication both
between professionals and between OAT structures: internal shared guidelines should inform the
selection of a target population and a suitable database should facilitate the circulation of data
between the professionals involved in the care of each patient.
CONCLUSIONS
The advent of new generation OATs in the Italian pharmaceutical market is not expected to require
radical changes in the organization of OAT centres, but a re-modulation of the current activity. The
new therapies are generally considered like a good opportunity to improve patients compliance and
Qol and are expected to be well-accepted by clinicians. Cultural and technological investments will
be necessary for an adequate and selective administration of Dabigatran and other new OATs.
Understandably, clinicians stated to be available to change their minds after the market access. It
could be useful to widen the sample of this survey and to compare the current answers to an ad hoc
interview to be carried out after at least one year of commercialization.
88

CONCEPTUAL FRAMEWORK FOR ORGANIZATIONAL MODEL ASSESSMENT OF HOSPITAL
CENTERS (HC)
Ana Simões1 ,3, Américo Azevedo1 ,3, Suzete Gonçalves2
1 INESC Porto, Porto, Portugal, 2 Instituto Superior de Serviço Social do Porto, Porto, Portugal, 3 Faculdade de Engenharia
da Universidade do Porto, Porto, Portugal
CONTEXT
Given the pressures for healthcare reforms to improve quality of care, patient satisfaction,
efficiency and also to reduce costs, many healthcare systems are using integrated healthcare
delivery systems to reach these desired goals. In Portugal, in 1999 was created an integrated form
of delivery hospital care, the "Hospital Centres" (HC). This form of organizing delivery hospital care
can be viewed as a horizontal integration. Nowadays, he have in Portugal 23 HC, however, this is
not available any evaluation of this organization way of delivery hospital care.
METHODS
We intend to develop a conceptual model that considers relationships between the components of
the HC and also incorporates key indicators to assess the performance resultant of the integration
process. Thus, the conceptual framework we intend to use is based on the framework presented by
Lukas et al. (Lukas et al., 2002). This conceptual model proposed is based on the sequential phases
of the process to achieve an integrated hospital care. At an initial phase, the management is
concerned with the coordination and integration of the main structures, functions and processes
(functional integration). These integrations and coordination's expect to increase HC integration
that includes the coordination among parts of the HC (HC integration). This coordination will lead to
HC performance improvement.
RESULTS
We hope to have some results regarding structures supporting and promoting integration at the
end of 2012. We intend to have results of the staff survey at the end of the first semester of 2013,
and a draft of performance indicators at the end of 2013.
CONCLUSIONS
Our objective in this research project is to develop a conceptual framework to evaluate the success
of this form of organizing hospital care delivery and to help HC to improve the strategic and
operational alignment. The framework presented here attempts to evaluate the degree of
integration and the performance of the Hospital Centre. The proposed framework can be viewed as
a way to improve the processes and structures integration, in order to improve efficiency,
coordination and performance. If we achieve the proposed objectives we will support the politicians
and the decision-makers to improve the current way of organizing hospital care and thus, have a
more efficient, cost-saving and rational hospital healthcare system.
89

COMPREHENSIVE VALUE ESTIMATION OF ADALIMUMAB-BASED TREATMENTS: COVET STUDY
Andrea Marcellusi1 ,2, Lara Gitto1 ,3, Patrizia Giannantoni2, Francesco Saverio Mennini1 ,4
1 CEIS Sanità (CHEM – Centre for Health Economics and Management), Faculty of Economics, University of Rome “Tor
Vergata”, Italy, Rome, Italy, 2 Department of Demography, University of Rome “La Sapienza”, Italy, Rome, Italy, 3 DEMQ,
Facoltà di Economia, Università di Catania, Italy, Catania, Italy, 4 Department of Accounting and Finance at Kingston
University, London, UK, London, UK
CONTEXT
The value of a drug can be expressed as the needed cost to increase a health unit. However, an
estimation of an index that summarises the value of a molecule with multi-indication is a complex
process. The Covet study had the specific objective to perform a comprehensive economic
evaluation of Adalimumab.
METHODS
An Econometric algorithm has been developed to estimate the total economic value of Adalimumab.
This value was calculated as the sum of the cost per QALY gained in the treatment of rheumatoid
arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease and psoriasis. The sum was
weighted by prevalence data for each of the diseases considered. Through a systematic literature
review analysis the cost per QALY gained when assuming other anti-TNF drugs has been
extrapolated; then a Boston Matrix has been developed to establish the relationship between
demand (prevalence of the disease) and health supply (e.g. the willingness to pay - WTP - of the
health care authorities). Finally, a League Table has been built in order to compare the costeffectiveness
of Adalimumab with other innovative molecules. A sensitivity analysis based on the
variability of Economic Evaluation model of Adalimumab has been performed to assess the
robustness of the results.
RESULTS
The total economic value of Adalimumab in Italy amounted to € 27,700. The sensitivity analysis
showed a cost per QALY gained ranging between € 19,487 and € 32,453. The analysis of the
Boston matrix, developed for each pathology, indicates that the cost per QALY gained of
Adalimumab was generally below the common WTP with the exception of psoriasis (€ 52,600). In
comparison with innovative molecules, the total economic value of Adalimumab was positive and
sustainable.
CONCLUSIONS
The study provides a first indication of the total economic value of Adalimumab that is below the
threshold value for health care interventions for all the main pathologies treated with this molecule.
Results of the study are helpful for decision makers, who should ensure that patients have equal
access to a cost-effective treatment, as well as promote research and development of innovative
molecules with greater cost-effectiveness ratio.
90

SOCIAL IMPACT OF ADALIMUMAB IN THE ITALIAN PERSPECTIVE
Andrea Marcellusi1 ,2, Lara Gitto1 ,3, Patrizia Giannantoni2, Francesco Saverio Mennini1 ,4
1 CEIS Sanità (CHEM – Centre for Health Economics and Management), Faculty of Economics, University of Rome “Tor
Vergata”, Rome, Italy, 2 Department of Demography, University of Rome “La Sapienza”, Rome, Italy, 3 DEMQ, Faculty of
Economics, University of Catania, Catania, Italy, 4 Department of Accounting and Finance at Kingston University, London,
UK
CONTEXT
The assessment of indirect costs constitutes an extremely important issue when managing chronic
diseases. Patients‟ lost productivity is often overlooked by decision-makers, although it is
fundamental for the estimation of the true economic impact of the disease. The objective of this
study was to estimate the social savings obtained with Adalimumab compared to standard therapies
for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease
and psoriasis).
METHODS
Five different economic evaluation models have been developed to estimate the cost effectiveness
of Adalimumab vs. standard care for each of the diseases - rheumatoid arthritis, psoriatic arthritis,
ankylosing spondylitis, Crohn's disease and psoriasis - treated, as indicated by the European
Medicine Agency (EMA), with the biologic drug. The cost of treatment was estimated both from the
perspective of the Italian National Health System (direct costs) and considering a social perspective
(direct costs + loss of productivity). A sensitivity analysis, based on the variability of model
parameters was performed, in order to assess the robustness of the results.
RESULTS
In the base case scenario, the average annual social cost (weighted for prevalence data of each
pathologies) per patient amounted to € 1,536 if treated with standard care, compared with € 1,201
if treated with Adalimumab. Adalimumab treatment would allow a reduction of 9.18% of the total
social cost (€ 1.42 billions) if 30% of these patients were treated with this molecule. The annual
saving in social costs can vary from 7.8% to 13% when the average market share of Adalimumab is
30%.
CONCLUSIONS
Adalimumab has a significant impact in reducing social costs for all the diseases considered in this
study. These aspects, often neglected in decision makers‟ assessments, should, instead, when
considering innovative technologies as biologic drugs.
91

RESEARCH ON THE NEED FOR “MEDICAL HOME PATRONAGE” SERVICES IN BULGARIA
Antoniya Yanakieva
Faculty of Public Health, MU Sofia, Sofia, Bulgaria
CONTEXT
"Medical home patronage" is basic medical care service, including care for patients, respectively for
children, or psychiatric care and housework. It takes place in a home environment or territory of
residence of the patient. The specificity of this type of service is that the patient or her relatives
determine the type and quantity of the care service, which is coordinated with the doctor and the
service contractors. The aim is to carry out medical care at home. This achieved through active care
which aims to improve and stabilize the patient's health and to avoid or shorten the stationary stay.
METHODS
Research methods used: The project included 300 in-patients in various hospitals in the country.
The survey was conducted in the following hospitals: Sofia: UMBALSM "N. Pirogov, "Military Medical
Academy, 5th Hospital, Pleven: Hospital" G. Stranski ", Plovdiv: University Hospital" St. George "EAD,
Varna: Hospital" St. Anna - Varna "JSC, Burgas "Hospital - Bourgas" AD The method of analysis and
synthesis of scientific literature includes: Sociological methods (Inquiry method, Documentary
method), Statistical methods (Analysis of quantitative and categorical frequency distributions,
Variation analysis, Graphical analysis).
RESULTS
Gender distribution of respondents is as follows: 75% are women and 25% were male. Among the
patients interviewed most significant group of people aged 40-58 years is 47.6 %. Here the group of
those over 59 years is 33.3% and the youth below 39 years - 19%. The respondent`s expectations
about a medical care service, related to medical home patronage, are mainly associated with home
visits by a doctor, injections and others medical manipulations, visit from a caretaker, nursing
supervision, examination by a physician, health services. The results of the survey with regards to
the financial resources: 45% of those who identify themselves as familiar with the nature of the
service indicated that they would allocate for it BGN 50 (ca. 25 €) per month, while the majority of
people who say they do not know this type of service would spent more money on it – BGN 51-100
(39.6%).
CONCLUSIONS
1. The service "Medical home patronage" allows limiting and even reducing rising health care costs.
This includes the rapidly increasing costs of hospital stay and the more efficient use of financial
resources.
2. Majority of the population is not likely to benefit from this type of service if it is not funded by
an institution or relatives due to the inability to allocate sufficient funds from the household
budget. With the increasing age of the patient, his/her inability to pay for such service also
increases.
3. Service under the “Medical home patronage" requires to put the patient at the centre of
attention and care, fully consistent with its expectations and desires.
4. For the population in the active workforce, it is critical to provide decent care for their sick
relatives, which in turn would reduce their absence from work.
92

CONCEPTUALIZING AND MEASURING PERFORMANCE IN THE DOMAIN OF NURSING CARE: A
SYSTEMS APPROACH
Carl-Ardy Dubois, Danielle D'Amour, Marie-Pascale Pomey, Francine Girard, Isabelle Brault
University of Montreal, Montreal, Canada
CONTEXT
Despite the critical role of nursing care in determining high-performing healthcare delivery,
nursing‟s contribution most often remains invisible to policy-makers and managers and
performance science in this area is still at an early stage of development. The objective of this study
was to develop a theoretically and empirically based framework to conceptualize nursing care
performance and to identify an integrated set of evidence-based nursing-sensitive measures for
evaluating the performance of nursing care.
METHODS
We carried out a systematic review of published literature across three databases (MEDLINE, EMBASE
and CINAHL), focusing on literature between 1990 and 2008. Screening of 2,103 papers resulted in
final selection of 101 papers. The analysis and interpretative synthesis involved constructing a
general interpretation grounded in the findings of separate studies and then integrating evidence
from across studies into a coherent theoretical framework comprising a network of constructs.
Using a detailed template, the analysis focused first on 31 papers with theoretical or conceptual
frameworks; the remaining 70 articles were used to strengthen and consolidate the findings.
RESULTS
Current conceptualizations of nursing care performance mostly reflect a system perspective that
builds on system theory, Donabedian‟s earlier works on healthcare organization, and Parsons‟
theory of social action. Drawing on these foundational works and the evidence collated, the Nursing
care Performance Framework (NCPF) we developed conceptualizes nursing care performance as
resulting from three nursing subsystems that operate together to achieve three key functions: (1)
acquiring, deploying and maintaining nursing resources, (2) transforming nursing resources into
nursing services, and (3) producing changes in patient conditions. These three functions are
operationalised through 12 dimensions that cover 52 variables. No individual model among the 31
collated covers this entire domain. Rather, the different models show a variety of combinations of
potential variables. However, for nearly all the models, the scope of nursing care performance
variables extends to more than one subsystem. 25 of the 31 models include indicators related to all
three subsystems.
CONCLUSIONS
A systems approach provides a comprehensive and integrated framework that allows performance
evaluation of both the overall nursing system and its subsystems. By incorporating the three
functions described above, the NCPF offers an effective way to compile a complete picture of overall
nursing care performance in any setting. Such an approach widens the view of nursing performance
to embrace a multidimensional perspective that encompasses the diverse aspects of nursing care.
While the NCPF specifies core aspects of nursing performance, it allows for variations in the
combinations of indicators according to different contexts and priorities. This framework offers
managers appropriate guidance to devise a set of performance measures that encompasses all
functional areas of the nursing system, covers its structural features as well as processes and
outcomes, considers both short-term and long-term issues, and provides a cross-functional view of
the nursing system and of the interdependence among its different functions.
93

HOW DOES PRENATAL CARE AFFECT THE BIRTH MODE?
Christine Vietor, Julia Weller, Andrea Gillessen, Anita Kettelgerdes, Torsten L Hecke
Techniker Krankenkasse, Hamburg, Germany
CONTEXT
98% of German children are born in hospitals. The increasing rate of caesarean sections as well as
the grade of professionalism in medical care for preterm delivery affects the quality of mother´s
and baby´s life. They are tying up increasing financial resources, too. Antenatal care, where risks
are identified and managed and preliminary decisions are made for birth mode is performed by
gynaecologists and midwives. Also health consequences of birth mode are, especially if they occur
after years, no longer in the service area of the maternity hospitals. Multi-sectoral quality standards
or treatment guidelines are missing.
METHODS
A team of data analysts and health care managers of Techniker Krankenkasse (TK) performs an
analysis of pre- and postnatal billing data. TK has 8 million members and is one of the largest
statutory health insurances in Germany. German health insurances don´t have primary medical
data. But billings include information on diagnoses, medical procedures and some sociodemographic
characteristics. So we can use data not only for check our payments but also the
results of provided health care. To differentiate between the caesarean section from vaginal delivery
clusters of German diagnosis related groups (GDRG) are formed (GDRG O01, O02, O60). The
newborns, especially premature babies should be differentiated both by the DRGs P01, P03-06, P60-
67, on the other by means of cluster based on ICD (P07.-P08.) as an equivalent to birth weight.
RESULTS
Approximately 55,000 births in 2008 are the basis of the analysis. The children's data are linked to
the mother´s, if possible. Data are available for the period of one year before and two years after
birth. T-tests are used to examine whether significant differences in the prenatal and postnatal
services and disease, differentiated by birth modalities are identified. The results shows if the
action of prenatal care by gynaecologists or midwives or documented indications of women vary
between the clusters. Furthermore, it shows whether the mode and place of birth influence the
scope and measures of medical indications in mother and child after birth. The aim is to establish
indicators for the development of health care management approaches and allocation models. They
can be used in contracts for integrated care between TK, hospitals, midwives and gynaecologists.
CONCLUSIONS
In Germany, remuneration of midwives, doctors and hospitals is sector-separated. Basically, the
service providers in obstetrics are in competition to each other - the provision of birth utility
services rarely occurs in networks. Medical documentation is evaluated separately by each sector
only. For expectant parents in this situation there is little transparency with a high pressure
decision. Still, there is no evidence for the causes of the rising number of caesareans. And the
hypothesis that high numbers of cases in a hospital provide the best care for a premature baby is
not yet proven. Midwives, hospitals, physicians and payers have different opinions about which are
also guided by financial interests. Data analysis can help to initiate an objective, patient-centred
discussion.
94

IMPROVING HEALTH CARE IN WOMEN WITH UTERINE FIBROIDS BY USING AN INTEGRATED
CARE MODEL
Claudia Junkmanns, Peter Dueker, Susanne Klein (presented by Christine Vietor)
Techniker Krankenkasse, Hamburg, Germany
CONTEXT
Treatment with magnetic resonance-guided focused ultrasound (MRgFUS) is an example how
Techniker Krankenkasse (TK), a social health insurance company in Germany, used an integrated
care model to improve quality of health care in women with symptomatic uterine fibroids. Our goal
was to adequately inform the relevant women about all their therapeutic options and to decrease
the rate of hysterectomies and other invasive procedures. This should be achieved with a better
cooperation between radiologists and gynaecologists.
METHODS
At the beginning of 2010, a selective contract was concluded with one of four sites in Germany
which offers MRgFUS. The contract links and regulates the interdisciplinary and cross-sectoral
cooperation of the participating players. Thus, a special consultation hour could be established and
TK insured women gained access to this innovative, non-invasive treatment of symptomatic
fibroids. The success of the integrated care model and the achievement of the set goals were
evaluated by assessing internal data and the satisfaction of women attending our model.
RESULTS
Until now 155 women have been enrolled to our integrated care model. Of these, 77 were suitable
for MRgFUS and were consequently treated. Only two of them needed additional operation later on
due to relapse. Currently, a questionnaire on the satisfaction of participating women is being
initiated. Results will presumably be available by end of March 2011 and can be presented then.
CONCLUSIONS
As measured by the prevention of invasive treatment, due to cross-linking of inpatient and
outpatient care, as well as interdisciplinary cooperation, integrated care could be achieved which
improves the quality of health care for TK insured women with symptomatic fibroids. Moreover,
reactions from other health care providers, interested in contracting MRgFUS with TK, show that our
commitment also serves to promote an innovative therapeutic procedure. As MRgFUS is not yet a
service in the catalogue of benefits offered by the social health insurance funds, integrated care
models are an applicable tool for a social health insurance company to actively design the health
care system in Germany.
95

THE USE OF ROOT CAUSE ANALYSIS FOR ERROR DETECTION IN HISTOLOGY - IMPACT ON
QUALITY AND SAFETY OF PATIENTS
Umberto Restelli1, Emanuele Porazzi1, Pamela Morelli2, Emanuela Foglia1, Marzia Bonfanti1, Michela Ruspini3,
Giuseppe Banfi4
1 Centre for Research on Health Economics, Social and Health Care Management (CREMS) - Università Carlo Cattaneo -
LIUC, Castellanza (VA), Italy, 2 Hospital of Novi Ligure, Novi Ligure (AL), Italy, 3 Hospital Authority Fatebenefratelli e
Oftalmico, Milan, Italy, 4 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
CONTEXT
Safety of patients is crucial for healthcare organizations and for regulating bodies which considers
this topic one of the most important areas for achieving accreditation by hospitals, and for assuring
quality to consumers associations. Errors are an integral part of every human system, including the
complex system of Anatomic Pathology. Previous Anatomic Pathology studies have focused on
errors in diagnosis and have not considered problems related to the histology preparation of
routine processes which have an impact on the overall quality of the processes. The study aimed at
widening the procedural error prevention culture.
METHODS
Root Cause Analysis (RCA) was applied to the entire process of histology preparation to identify the
root cause of each problem incurred. An 'a priori' list of errors that could occur in the histology
preparation processes was defined and a trained technician recorded on a survey form the errors
encountered during the process during a three month period in a laboratory of a leading hospital in
Regione Lombardia. Starting from the errors encountered, the method of "fishbone diagram" was
applied in order to identify potential causes and areas where the errors developed and "Five whys"
method was applied in order to reach the root cause of each problem identified. Finally, possible
corrective measures were assessed in order to eliminate the identified causes.
RESULTS
Over the whole period of the study 8,346 histological cases were reviewed, for which 19,774
samples were made and from which 29,956 histologies were prepared. 132 errors were identified
during identification (6.5% of the total), sampling (28% of the total), processing (1.5% of the total),
inclusion (4.5% of the total), cutting (23% of the total), colouring, (1.5% of the total), labelling and
delivery (35% of the total) phases.
CONCLUSIONS
Concerning the quality of the process analyzed, RCA proved to be a useful and easy to use
technique: it can be considered an important step for the identification and prevention of errors;
that are frequently secondary to multiple causes. It is possible, with the provision of education and
training, for operators to be aware that they play a central role in the risk management process, and
to highlight points of relevant importance for improving the methodology and assuring procedural
safety. As documented in literature, a decrease in the number of errors would have a positive
impact in the quality of the healthcare services provided and would lead to a decrease of the
insurance premiums for hospitals, contributing to the sustainability of the whole system.
96

PATIENT PARTICIPATION THROUGH PATIENT-CENTERED EHEALTH APPLICATIONS: A UTOPIA?
Femke Vennik, Samantha Adams, Kim Putters
Institute of Health Policy and Management, Rotterdam, The Netherlands
CONTEXT
In most western countries, citizens are increasingly expected to be „informed' decision makers with
regard to their health. Patient-centered eHealth applications, especially those focusing on the
strengths of patients and their (social) networks, are expected to help them fulfil this role. The
expectations for such applications are great, as they have the potential to give patients a more
active role in their own healthcare processes. But, do they? This paper examines how patientcentered
eHealth applications influences the participation possibilities of patients, using the Dutch
„MijnZorgnet.nl' („my health net'); an online platform where patients and professionals exchange
information through web-based communities.
METHODS
This research is based on a qualitative design: a single case-study in the Netherlands, a country that
is quite far in advancing patient participation. We first conducted a policy analysis in order to
identify how „participation of patients' is defined by policy makers. We reviewed policy documents
related to eHealth and patient participation over two cabinet periods: „Balkenende IV' (2007-2010)
and „Rutte' (2010-the present). These two cabinets were selected because they represent the latest
policy views of the Dutch government. We then examined the specific case MijnZorgnet.nl, using a
mix of qualitative methods: Semi-structured interviews with users of the website (patients,
healthcare providers) and employees of the firm MijnZorgnet (n=11); Observations of 5 web-based
communities on MijnZorgnet.nl (on the basis of maximum variation) for the duration of 6-12
months; Participant observation at MijnZorgnet for approximately one year. The interviews were
transcribed verbatim and, together with the observations, analyzed in AtlasTI.
RESULTS
This research is still in progress, as data is still being collected. We therefore present the working
results of the first round of analysis. Our policy document analysis, interviews and observations
revealed two predominant themes. First, the opportunities for patients to participate depends,
amongst others, of the characteristics of the patient, the space that patients receive from health
care professionals to actively participate in their own health care processes and the functioning of
online communities. Second, how well an online community functions depends largely on the
perspective you take to look at the community. For instance, an employee of MijnZorgnet may think
that a community is functioning well because it has many members, whereas a patient could have
the opinion that the community is not functioning, as he is looking for information which cannot be
found in the community. To clarify the results more, the upcoming data collection is important.
CONCLUSIONS
This study shows that availability of a patient-centered eHealth application does not automatically
lead to good and equal participation opportunities for patients, as participation opportunities are
depending on factors such as patient characteristics and the functioning of patient-centered
eHealth applications. The introduction of eHealth applications should therefore not be assumed to
automatically lead to patients who are able to participate actively in their own health care
processes. This is an important message for policy makers who are trying to find solid ways to
stimulate patient participation. This presentation is intended to stimulate discussion about this
issue among delegates at the EHMA conference, with the intent to raise awareness for the fact that
policy ideals and the way it works out in practice is not always the same and that the utopia that a
patient-centered eHealth application directly leads to patient participation, has to be nuanced.
97

HOSPICE CARE IN BULGARIA - WHO PAYS, WHO PROVIDES?
Silviya Aleksandrova-Yankulovska, Gena Grancharova, Toni Vekov
Department of Medical Ethics, Health Management and Information Technologies, Faculty of Public Heath, Medical
University of Pleven, Pleven, Bulgaria
CONTEXT
The modern hospice movement started in 1967 with establishment of St Christopher's hospice in
London by Dame Cecily Saunders. Hospice programmes nowadays exist in over 100 countries. In
Bulgaria hospices were firstly defined as health institutions only in 1999 by the Health
Establishments' Act. Next year‟s many hospice initiatives were undertaken but they were not
supported by the Government or by insurance system. Most of them didn't start or closed their
activity because of financial constrains. The aim of our research was to investigate the opinion of
managers and patients' relatives in existing Bulgarian hospices about their financial problems.
METHODS
The study was performed in 2008-2009. The information about hospice initiatives after the
adoption of the Health Establishments' Act has been gathered from the national registration system
and compared with the registers of health institutions supported by the Regional Health Authorities.
On the grounds of such information a database of active hospices with their contact details has
been created. Three types of questionnaires were designed: for hospice managers, as well as for
hospice staff and hospice patients' relatives. Information has been collected through telephone and
face-to-face interview, and self-administered questionnaires sent and received by surface mail. Out
of 35 active hospices that were included in our database, a compliance to participate in the study
has been received from 29 hospices (82.9%) - 17 stationary hospices with beds and 12 hospices at
home. Altogether, 29 managers and 216 patients' relatives responded to the questionnaires. Data
processing was performed by SPSS v.13.
RESULTS
According to hospice managers the leading problems that have great impact on their activity were
related to financial constrains - 70.6% for stationary hospices and 66.7% for hospices at home. The
monthly costs of care in a stationary hospice that is to be paid by the patients and relatives varied
from 300 to 700-800 euro. Very few managers pointed out that they were supported financially by
donations, European projects or by local community budgets. Hospice care at home is less costly
(150-300 euro per month) as the basic caregivers were the patients' relatives. The opinions of
patients' relatives in stationary hospices showed that for 30.6% the costs of stay was very high and
not affordable, for 23.1% it was acceptable for a short period of time and 45.4% pointed out the
cost of care was not a problem for them. The same tendency was found for the hospices at home.
CONCLUSIONS
From the beginning hospice initiatives were not supported financially by the Government or
Insurance Fund. There is only one clinical path for palliative care in which terminally ill cancer
patients can be paid for 20 days of stay in hospice or in a palliative care unit within a 6-month
period. The average monthly payment is 3-8 times higher that the average month salary in Bulgaria
or even higher compared to the pensions of elderly people that are mostly in need of hospice care.
This means that hospice care is not affordable for the average Bulgarian citizens. The responses of
relatives about the cost of hospice care do not reveal the real picture and needs because the
predominant part of hospice patients nowadays is from well-off families. That's why the support of
hospice care by the Government and by insurance system should take a priority in Bulgarian health
reform.
98

OUTSOURCING IN TURKISH HOSPITALS: A SYSTEMATIC REVIEW
Yasemin Akbulut, Gözde Terekli, Turkan Yildirim
Ankara University Faculty of Health Sciences Department of Health Services Management, Ankara, Turkey
CONTEXT
Outsourcing has become a basis strategy in the public hospitals and has recently grown
considerably in popularity. Outsourcing services include clinical areas such as, radiology, and
nonclinical areas of catering, cleaning, laundry, and computing. The impetus for this trend was the
initiated by the Ministry of Health in Turkey with the fact that private sector pressures and
competition would make public sector more efficient. However, some researchers have reported
discrepant results regarding the effectiveness and efficiency of outsourcing services in public
hospitals.
METHODS
The aim of the study is to compare and integrate of different research findings carried out on
outsourcing services in the hospitals in Turkey through a systematic review and to make suggestion
for future researches. Systematic reviews are secondary research projects that compile all the
randomized trials addressing a particular question of interest. Candidate studies were located using
the Institutions of Higher Education Database in Turkey for dissertations, ISI-Web of Science,
PubMed and Medline databases. Searches were conducted using the all years inclusive. A set of
keywords was developed to use in the initial search. The keywords included "outsourcing,
outsourcing in hospital, using outside sourcing and outsourcing in Turkey". After searching, it was
used inclusion and exclusion criteria (full text, national or international research articles and
dissertations, conducted only in the hospitals located in Turkey, published in Turkish and English)
to select studies.
RESULTS
A total of 15 studies (8 dissertations, 7 articles) published between the years 2005 and 2011 were
identified for inclusion in the present review. Some of the research (60%) was carried out in public
hospitals and 40% with the public and private hospitals. The studies were carried out with hospital
administrators (46.6%), patients (20%), hospital workers (26.6%), and the cost of the hospital
records (6.6%). Some of the research (73.3%) was conducted to determine the reasons and areas of
using outsourcing services and 26.6% the level of satisfaction of the outsourcing services. It was
found that the level of satisfaction of patients was above average (n=2), hospital staff were found
below average (n=1), and managers' satisfaction were as high level (n=1). Some studies (38.8%)
indicate that the outsourcing service has increased the quality of services, 33.3% has decreased the
cost of services, and 27.7% has increased the productivity and efficiency.
CONCLUSIONS
Most of the studies (n=14) based on information and opinions of hospital workers, managers and
patients. According to the results of these studies, the outsourcing services have decreased the
costs, increased the productivity and the quality of services. In only one study it was examined the
effect of outsourcing services on the hospital cost. In one study the satisfaction level of hospital
workers was found as low. According to the results, it can be identified that it is required to some
empirical research that will determine the effect of outsourcing services based on the indicators of
objective quality, productivity and costs, especially risk analysis research, in public and private
hospitals in Turkey.
99

NEW PROPOSED SCHEMES FOR CHRONIC PATIENT MANAGEMENT IN REGIONE
LOMBARDIA."CHRONIC RELATED GROUPS (CREG)" UNDER TESTING IN FIVE LOCAL HEALTH
AUTHORITIES AND THE EXPERIENCE OF "PRIMARY CARE GROUPS" PCG) IN THE PAVIA LOCAL
HEALTH AUTHORITY, (LOMBARDY, ITALY), FOR CARE DELIVERY TO CHRONIC PATIENTS
Guido Fontana1, Simonetta Nieri1, Carlo Cerra1, Sergio Pellegrino2, Roberto Nardi2
1 Pavia Local Health Authority, PAVIA, Lombardy, Italy, 2 GP working group, PAVIA, Lombardy, Italy
CONTEXT
In Lombardy new ways to arrange financing to care for chronic patients are currently under scrutiny.
Five Local Health authorities are testing the CREG (Chronic Related Group), whose objective is to
ensure continuity of care pathways for patients with chronic diseases to be managed by a single
entity which may be groups of GPs, a non-profit organization, a foundation, a hospital. The local
health authority of Pavia, which is not directly involved in the trial of CREG, however, has long since
started an experimental project, for the treatment of chronic patients by GPs organized in
advanced forms of associations.
METHODS
The goal of the project, named “Primary Care Groups" (PCG), was to take charge of the welfare
problems of patients suffering from those illnesses that involve almost a quarter of people in
charge to the family doctor: diabetes mellitus and hypertension. As a whole the project has come to
involve, in 2011, 13 groups of GPs in advanced medical associations, for a total of 55 professionals,
13% of GPs operating in the province. These doctors make use of specialist services at the site of
delivery of care, useful to the completion of the course of the patient. The search for
appropriateness in the use of resources is achieved through the definition and use of diagnostic
and therapeutic pathways shared (PDT) to ensure the patient the opportunity to take advantage of
diagnostic tests and of therapies that are the most appropriate for their clinical situation.
RESULTS
In the Pavia LHA, in the period between 1 January 2007 and March 31 2011, 6916 chronic patients
(718 diabetics, 735 diabetics-hypertensive, 5463 hypertensive), followed by 44 GPs, have been
studied and their clinical data were routinely recorded in each patient's GP EMR, whereas the LHA's
database was populated with periodical reports extracted from the GPs' EMR and with relevant
administrative data. Table 1 shows results obtained in terms of process and adherence to the path
between patients followed by PCG, compared with data of all patients referred by other physicians
in the province, not organized in PCG. Data shows that patients followed by GCP make a higher
percentage of checks provided in PDT. Changes of the parameters under study that occurred in the
period under study were also evaluated. For the year 2010 (Table 2-3-4) consumptions in terms of
drugs, specialist services and hospital admissions, for the three different groups of patients, were
also compared.
CONCLUSIONS
While outlining the possible new emerging roles for the professionals involved and the
organizational models likely to be adopted, this paper provides elements of discussion about the
cost effectiveness and efficacy of the new care schemes against the traditional ones, with the
ultimate goal to validate them and to promote reform in Regional Primary Care. General
Practitioners have been able to manage chronic diseases in an active way, with an improvement in
the appropriateness of care using an operational model (PDTA-INDICATORS-INCENTIVES) agreed,
and utilizing the support of LHA in the verification of paths and the results. This experiment has
shown that it is also possible to improve the values of the parameters provided by the paths by
applying a more strict surveillance on patients suffering from chronic disease. Thank to this
experience PCG have developed a collaborative with LHA in the pursuit of regional-oriented clinical
governance objectives.
100

MEDICAL SERVICE CENTRES – FIXED INCOME VERSUS INDIVIDUAL INCOME WITHIN
COOPERATIONS OF SHI-DOCTORS
Josef Farnschläder, Harald Stummer
Umit, Hall in the Tyrol, Austria
CONTEXT
In Germany, the economic situation of many SHI physicians is under pressure since many years.
Probably, this could be improved by means of cooperation, e.g. within a Medical Service Unit (MSU).
However, the profit sharing agreements within an MSU can be a risky having conflicts. The present
paper investigates attitudes towards profit sharing within those organizations.
METHODS
After discussing theoretical implications from game theory, the present papers draws on problemcentered
interviews of SHI physicians within MSUs. The interviews are recorded, transcribed,
summarized, explicated and structured.
RESULTS
In nearly all investigated cases, the profits were not shared on turnover but on a fixed percentage.
According to game theory, there is the fear of disturbing cooperative behaviour and promoting
egocentrism when doing not so. Another main reason mentioned are the difficulties valuing
interrelated services rendered.
CONCLUSIONS
Put in a nutshell, cooperation is assisted by means of having shared visions and a fixed income
distribution.
101

PATH MANAGEMENT IN MULTIMODAL PAIN MANAGEMENT – IMPACT ON QUALITY AND
COSTS? EVIDENCE FROM GERMANY
Tobias Romeyke, Harald Stummer
Umit, Hall in the Tyrol, Austria
CONTEXT
The cost-intensive care of a growing number of pain patients means that hospitals specialising in
interdisciplinary pain therapies as part of providing acute inpatient care are placed under increasing
pressure in ensuring that the quality of care remains high while the costs incurred remain low.
METHODS
The present paper compares the clinical and economical outcome of 65 patients divided into two
groups - one with the pathway, one without. This study investigates whether this objective can be
achieved by means of a clinical pathway (CP). Analysis is necessary of the core processes of pain
therapy in respect of quality and costs, taking account of the ages and co-morbidities of the two
groups of subjects. This analysis examines the pain intensity, the costs incurred for the care
personnel, therapy minutes involved, and hospitalisation duration.
RESULTS
It can be shown that costs can be lowered as a result of the CP and that, despite a reduction in the
duration of hospitalisation, the pain intensity on being discharged from hospital is no lower than
for the comparison group without CP.
CONCLUSIONS
The present paper shows an evidence for the usefulness, but also the limits of pathways in
multimodal pain management.
102

MANAGED CARE - A PILOT PROJEKT OF STROKE MANAGEMENT IN AUSTRIA
Klaus Buttinger, Harald Stummer
Umit, Hall in the Tyrol, Austria
CONTEXT
The aim of the present paper is to analyze a managed-care project named “Integrierte
Schlaganfallversorgung (managed care in stroke)” in an Austrian Bundesland, especially to explore
potentials regarding the optimization patient treatment and regarding the education of health
professionals.
METHODS
Data was collected using clinical and ambulance data during a two-year period (N=1,549) and
analyzed using SPSS ©.
RESULTS
Looked in a nutshell, it appears that treating stroke in a managed care setting with standardization
of diagnostic and treating processes can improve therapeutic success, at least partially.
Surprisingly, the acuteness of the disease is mostly underestimated by the emergency doctors and
partly strokes are misinterpreted as other diseases in preclinical phase.
CONCLUSIONS
Overall, the present study is a pilot study; therefore the results need to be compared with similar
projects by the means of “benchmarking”. However, the clinical underestimation of stroke should
be approached, e.g. by means of continuous education for emergency doctors.
103

RAISING FUNDS FOR THE NATIONAL HEALTH SYSTEM: PHYSICIAN’S PERSPECTIVE.
Helena Pereira, Denise Santos
UAL, Lisbon, Portugal
CONTEXT
The European financial crisis turns the need to contain public spending a priority, making urgent
the definition of funding strategies for the national health systems (NHS) sustainability. The
Portuguese NHS is mostly financed by public budget and the main source of funding is general
taxation. Approximately 10% of GDP is devoted to health expenditure, which puts Portugal among
the countries with the highest level of health spending within Europe. Urgent intervention is
needed, not only to better manage the few resources available, as well as to find other funding
sources. We collected the perspective of physicians to this matter.
METHODS
We questioned almost 100 physicians, working in hospitals in Lisbon, about the measures that
should be implemented to control the "slippage" in the health budget, the most viable funding
sources for the NHS, and the best way to finance their own hospital service. Questionnaires were
statistically treated.
RESULTS
Physicians mainly think that the Portuguese model of funding should be closer to the one of the
USA. Public hospitals and senior hotels should also provide quality health tourism in partnership
with other European countries (especially for countries with surgery waiting lists). Cost containment
is crucial and single dose policies are considered a priority for this issue, as well as additional
control by hospital administrations.
CONCLUSIONS
Strategies' followed so far by European countries in order to fund healthcare became insufficient
due to the present world crises and consequent significant reduction of public resources available.
Even small measures may help to minimize this situation when applied to the national territory.
Physician's suggestions to overcome the need of funding are of great importance since they are the
ones that provide care and should not be ignored.
104

APPROACHES FOR OPTIMIZING THE FINANCIAL HOSPITAL MANAGEMENT AND QUALITY OF
SERVICES (THROUGH EXPERIENCE IN BULGARIA)
Jasmine Pavlova, Vasil Pisev, Nevena Tzacheva, Lora Afanasieva, Ivaylo Ivanov
FPH, MU, Sofia, Bulgaria
CONTEXT
For centuries hospitals are viewed as vital and necessary resources that should be managed for the
benefit of the community. As such, hospital management has a responsibility to provide health care
services that the community needs, at an acceptable level of quality, and at the least possible cost.
Cost finding and analysis can help departmental managers, hospital administrators, and
policymakers to determine how well their institutions meet these public needs. The quality of
service is a key ingredient in the success of hospital care. Service quality has become an important
research topic in view of its significant relationship to costs.
METHODS
The aim of this study was based on comparative analysis of data on the financing of hospitals and
health of the population in Bulgaria and European countries in recent years to suggest approaches
for optimizing the ratio between expenditure, quality of hospital services and achieved effects.
Tasks: Analysis of the structure of revenue and expenditure in hospitals; Assessment of regional
differences; Study of service quality based on questionnaires and standardized rating scales;
Comparative analysis of demographic indicators.
Material and methods: Review of the literature on discussed issues, Eurostat, NSI, NSSI, NHIF's
databases for the period 2000 - 2010. We used the documentary, economic, inquiry and expert
methods.
RESULTS
The hospital is the most complex institution in the modern health system. At the end of 2010 in
Bulgaria there are 347 establishments for health care with 48944 beds. Hospitals are 313 with
45842 beds. According to the Health Establishments Law hospitals are multyprofile and specialized.
The multyprofile hospitals are 164 with 32576 beds, and specialized - 149 with 13266 beds. The
consumption of the hospital system represents 60% of the whole financial resource of the health
sector. The modern hospital is a complex open system which consumes a large number of human,
material, financial and informatics resources. It produces medical services intended to protect and
ameliorate human health. The data analysis shows extensive type of hospital system with more
hospitals and beds compared to EU 27. In 2010 were hospitalized 1,9million persons (the total
Bulgarian population is 7,3million). This process generates increasing costs for the hospital system.
CONCLUSIONS
The financing sources for the Bulgarian hospital healthcare system are multiple: National Health
Insurance Fund - 477mil.Euro, Ministry of health - 266mil.Euro, Municipality budgets – 48mil.Euro,
direct payment from the population – 171mil.Euro. The hospital costs vary in wide ranges. They
depend on the specificity of the activity. The most expensive medical services are provided by
University hospitals which follows the logic that in this type of institutions are treated the most
complicated cases of patients. The main categories of costs include salaries, supplies, amortization,
interest, and bad debt expenses. Wages and salaries paid to employees are usually the largest
category of expenses for hospitals. Hospitals must be able to adapt to changing circumstances and
enhance the quality of care. The implementation of principles and tools of financial management
will contribute to optimize the hospital activities, to reach a balance between resources – business –
results.
105

DEVELOPING NATIONAL QUALITY MEASURES FOR INFANTS AND TODDLERS PREVENTIVE
HEALTH SERVICES AS A TOOL FOR DECISION MAKING
Keren Dopelt1, Nadav Davidovitch1, Itamar Grotto1 ,2
1 Ben Gurion University, Beer Sheva, Israel, 2 Public Health Services, Ministry of Health, Jerusalem, Israel
CONTEXT
About 40% of mother and child health-centres (MCHC) in Israel are operated by the Israeli Ministry
of Health (MOH), serving about 66% of Israeli infants' population, while the rest are operated by a
range of providers. Recently there has been a public debate who should be the provider of those
services: government or health funds. This debate also raised the issue of developing quality
measurements in order to compare and improve the services given in such centres.
METHODS
The process includes the establishment of a multi-disciplinary steering committee for quality
measures building and data collection stage. Retrospective data analysis of computerized records
of about 215,000 children from 174 MCHC born between 2005-2010, registered in the Israeli
Ministry of Health MCHC. Data included quality measures on vaccination rates, growth and
development surveillance and health outcomes. Data analysis includes independent sample t-test,
One Way ANOVA, χ2, linear and logistic regression.
RESULTS
In the first stage, the national steering committee decided to focus on four fields: vaccination,
nutrition, growth and development. Accordingly four sub-committees were established and quality
measures were developed and tested in these fields. While vaccination rates were high, performance
of the various screening tests was not satisfactory and decreased according to age. Differences
were found according to geographical regions and ethnicity.
CONCLUSIONS
This study serves as a foundation for quality measurements program in MCHC in Israel. It can serve
policy-makers for evidence based decision making while establishing priorities and effective
resource management. Currently the Israeli National Quality Measures program does not include
almost any measure related to children health or specifically to the infant and toddlers preventive
services. This innovative study can help to promote the field of children's health quality measures in
Israel and internationally. Several recommendations were presented to policy makers in Israel:
1. There is a need for institutionalizing comprehensive data collection in the preventive services
for infants and toddlers in Israel.
2. This program will promote the standardization of services to enable transparency for all
stakeholders.
3. There is a need to expand the program to further indicators, with an emphasis on the
continuity between preventive and clinical services and to stations operated by health
funds and municipalities.
106

ATTITUDES OF PHARMACISTS AND PHYSICIANS TO ANTIBIOTIC USE AND MICROBIAL
RESISTANCES - A PILOT STUDY.
Fátima Roque1 ,2, Clarinda Neves3, Sara Soares1, Mónica Ferreira1, Luiza Breitenfeld4, Odete Cruz e Silva1, Adolfo
Figueiras5 ,6, Maria Teresa Herdeiro1 ,7
1 Centre for Cell Biology - University of Aveiro (CBC/UA), Aveiro, Portugal, 2 Research Unit for Inland Development,
Polytechnic Institute of Guarda, Guarda, Portugal, 3 Hospital D. Pedro, Aveiro, Portugal, 4 Health Sciences Research Centre
– University of Beira Interior (CITS/UBI), Covilhã, Portugal, 5 Consortium for Biomedical Research in Epidemiology &
Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Santiago de Compustela, Galicia, Spain, 6 University of
Santiago de Compostela. Santiago de Compostela, Santiago de Compustela, Galicia, Spain, 7 Health Technology Research
Center (CITS/CESPU), Paredes, Portugal
CONTEXT
Excessive use of antibiotics has contributed to the spread of microbial resistances, an important
problem of public health. Inappropriate use of antibiotics, are attributed to inadequate prescription
and self-medication with antibiotics obtained from leftovers from previous courses or selfmedication
with antibiotics dispensed in pharmacies without prescription. This study sought to
evaluate reliability and reproducibility of two questionnaires on knowledge and attitudes
pharmacists and physicians about antibiotic use and microbial resistance.
METHODS
Two structured questionnaires, one for pharmacists and one for physicians, were constructed after
review of published studies and after performed a qualitative study designed with pharmacists'
focus group sessions. Our research was developed in an area of Statistically Territorial Unity
Nomenclature (NUT) II of Portugal, defined by Health Northern Regional Administration (ARS-N).
ARS-N was informed about the study and questionnaires were administered to each health
professional twice, at an interval of 2 to 4 weeks. Attitudes were measured using a continuous
visual analogical scale, with answers scored from 0 (total disagreement) to 20 (total agreement).
Statistic analysis included determination of intraclass coefficient (ICC) and Cronbach´s alpha, for
each questionnaire.
RESULTS
A total of 43 pharmacists and 32 physicians participated in this survey. Each questionnaire
evaluated 17 attitudes that were grouped in four dimensions of attitudes to antibiotic resistance:
perception of the problem, attribution of responsibilities, confidence and factors associated to
dispensing habits (in pharmacists questionnaire) or factors associated to prescription habits (in
physicians questionnaire). Six questions, related to the first three categories mentioned are
common for both questionnaires what permits to compare these attitudes between pharmacists and
physicians. All evaluated attitudes demonstrated good ICC for each questionnaire and the reliability
(Cronbach's alpha) was 0,624 for pharmacists' questionnaire and 0,711 for physicians'
questionnaire.
CONCLUSIONS
Both questionnaires are reproducible and valid to evaluate the attitudes and knowledge of these
two groups of health professional. These questionnaires proved to be a good tool for collecting
data, since it allows compare some attitudes between pharmacists and physicians, and to detect
differences among each professional group. Data collected from this questionnaire are important to
design interventions directed to pharmacists and physicians to improve antibiotic use, tailored
taking into account attitudes, knowledge and dispense or prescription habits of these health
professionals.
107

EDUCATIONAL INTERVENTIONS TO IMPROVE ANTIBIOTIC USE AND TO REDUCE COSTS
ASSOCIATED WITH INAPPROPRIATE CONSUMPTION.
Fatima Roque1 ,2, Sara Soares1, Luiza Breitenfeld3, Odete Cruz e Silva1, Adolfo Figueiras4 ,5, Maria Teresa Herdeiro1 ,6
1 Centre for Cell Biology - University of Aveiro (CBC/UA), Aveiro, Portugal, 2 Research Unit for Inland Development,
Polytechnic Institute of Guarda (UDI/IPG), Guarda, Portugal, 3 Health Sciences Research Centre – University of Beira
Interior (CITS/UBI), Covilhã, Portugal, 4 Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en
Epidemiología y Salud Pública - CIBERESP), Santiago Compustela, Galicia, Spain, 5 University of Santiago de Compostela.
Santiago de Compostela, Santiago Compustela, Galicia, Spain, 6 Health Technology Research Center (CITS/CESPU),
Paredes, Portugal
CONTEXT
Antibiotic resistance is an important factor of Public Health which is aggravated by the lack of
development of new antimicrobial agents. Infections with antibiotic-resistant organisms have been
associated with increasing length of stay on hospital, mortality and costs. The aim of this study is
to carry out a critical review about the effectiveness of educational interventions on health
professionals to improve antibiotic use, and costs associated, in primary care and hospital setting.
METHODS
Review all studies published, from January 2001 to December 2010, about educational
interventions in physicians and/or pharmacists to improve antibiotic use in primary care, by
searching the scientific MEDLINE database, using PubMed. Data extraction included study design,
type of interventions, population targeted, changes on total of antibiotic used and/or adherence to
guidelines, and, total costs with antibiotics before and after intervention.
RESULTS
Sixty eight articles presented the criteria for inclusion and were selected. Of these, 42 were
conducted in primary care and 26 in hospital setting. In most studies the interventions were
directed only to doctors, in others were directed to pharmacists and some interventions were
multidisciplinary, including, doctors, nurses and pharmacists and in 15 studies, interventions
included patients and their caregivers. The target diseases in different studies were mainly
respiratory infections and urinary tract. Twenty studies (48%) in primary care and seven studies
(27%) in hospital care, were experimental controlled randomized trial. Results on total consumption
and or guidelines adherence were reported as positive in 81% and 60% of studies, on hospitals and
on primary care, respectively. Unless some studies refer reduction in costs to antimicrobial use,
only in 4 studies authors analysed effectiveness of intervention in what concerns the relation of
intervention costs versus antimicrobial reduction costs.
CONCLUSIONS
Published studies are very heterogeneous, in what concerns study design, outcomes measured,
period of outcomes and definition of sample. Educational interventions in health professionals
revealed to be effective to improve antibiotic use, but there are little dates about costs benefits for
health systems with habits changes on antibiotic use and about intervention costs versus reduction
costs with antibiotic consumption decreasing.
108

INFLUENCE OF THE SELF-EFFICACY ON THE HEALTH BEHAVIOUR AMONG VOCATIONAL
EDUCATED YOUTH AND YOUNG ADULTS
Marja-Leena Kauronen
Kymenlaakso University of Applied Sciences, Kotka, Finland
CONTEXT
Recently, the socio-economic health inequality has increased. The harmful health behaviour in the
youth is regarded as a predictor of health problems in the adulthood therefore to adopt the health
living habits in the youth and in the young adulthood is economic from the national perspective.
Self-efficacy means person's belief in his own capability to manage on the challenges which he/she
regards important. Self-efficacy acts a remarkable role in the health behaviour formation. In this
paper, we investigate the health circle of the young adults. The elements of the circle model are
self-efficacy, health behaviour and health-satisfaction.
METHODS
The accumulative health circle is investigated by the structural equation model (SEM). The model is
estimated with lavaan-library in R. Data for the model is based on survey hold on spring 2011
among 16-29-years-old young adults (n=430). Self-efficacy is measured by questions related to the
management of everyday life, satisfaction to his own successes in the issues that are felt important,
confident to solve his own problems and try to follow his own aims at life. Health behaviour is
measured as an aim to support health in physical activity, rest, diet, smoking and alcohol
consumption. Health satisfaction is measured with question "How satisfied are you for your health?"
We also analyze how the health behaviour is associated with health satisfaction. To close our
accumulative health circle, we analyze how the health satisfaction is related to the self-efficacy. This
circle is analyzed between two groups: employed and unemployed young adults.
RESULTS
Results confirm that self-efficacy has a remarkable role in the health behaviour of employed young
adults. The self-efficacy was positively associated with health behaviour efforts. The higher the selfefficacy,
the higher was also health behaviour efforts to support the health. In this group, the health
behaviour was positively related to the health satisfaction. The satisfaction to health was also
positively correlated with self-efficacy. Health satisfaction was one source of self-efficacy. The
accumulative health circle was significant only in the group of employed young adults which
underline the role of the work as an important part of the young adult's life. Lack of the
accumulative health circle indicates the unbalance of the life situation. The finding shows that the
same health promotion models are not working with the employed and unemployed young adults.
Instead, among unemployed young adults, this accumulative health circle disappears indicating the
unbalance of the life situation.
CONCLUSIONS
The constituted structural equation model shows that the self-efficacy influences on person's health
behaviour while the health behaviour influence on person's satisfaction at his own health. The
satisfaction at his own health has a strong feedback effect on self-efficacy. Until these days, the
health education, especially with the informational content, has been an essential method in the
striving to formulate the individual health behaviour. The model shows an essential role of the selfefficacy
in the development of person's health behaviour. By supporting the person's skills to
manage the everyday life situations and by helping to succeed and progress in his desirable goals it
is possible to promote the development of the self-efficacy. The succeeded experiences as a result
of these efforts advance the development of the self-efficacy. In this study is showed a need for
developing a model to analyze the health behaviour among the unemployed young adults.
109

ASSESSING THE COSTS OF THE HEALTH PATHWAYS: THE CASE OF DIABETES IN AN ITALIAN
HEALTHCARE DISTRICT
Americo Cicchetti1, Matteo Ruggeri1, Daniela Bianco2, Silvia Colombo2, Emiliano Briante2, Paola Codella1,
Angelica Carletto1
1 Università Cattolica del Sacro Cuore, Roma, Italy, 2 Fondazione Ambrosetti, Milano, Israel
CONTEXT
Every year diabetes and its complications result in a large health expenditure. According to the
International Diabetes Federation the total cost of diabetes in the world varies between 367 and
667 billion Euros a year. The lack of integration and coordination in the management of
care increases the utilization of specialist services and inappropriate hospital admissions as well
as longer waiting lists. Progressively the health care systems of developed countries are
focusing the attention towards integrated management models which are based on the
centrality of the person.
METHODS
The objective of this study is to evaluate the economic impact of a diabetic pathway in the
health care district (ASL) CN2 of Alba-Bra (Cuneo). In this district was recently established a
program of integrated management of diabetic patients with general practitioners and local
services in order to improve care and rationalize the total spending for diabetes. The diabetes
service is active in three locations where there are 4 full-time diabetes specialists and 3 parttime
nurses, 2 psychologists and a cultural mediator. The cost analysis was performed by using
the data extracted from the administrative database of the ASL and the hospital discharge
records, referring to the year 2010. Data on 6624 patients residents in the municipality of the
ASL CN2 of Alba-Bra were included. Through this analysis it was possible to estimate the cost
drivers influencing the expenditure for the healthcare pathway of diabetic patients.
RESULTS
The total expenditure generated by the healthcare pathway of the diabetic patients detected at
the ASL, is 10.672.966 euro. The average cost per patient is 1.711 euros. The main
determinants of expenditure are hospital admissions (28.2%) and drugs (pharmaceutical care
26.9% and direct distribution 3.3%). Among the therapeutic classes those with the greatest
impact on pharmaceutical expenditure are substances acting on the cardiovascular system,
renin-angiotensin system and hypoglycemic drugs. This indicates the presence of comorbidity
in patients with diabetes. The cost of outpatient services amounted to 21.7% of total spending
and the remaining percentage of expenditure is attributed to self-glucose monitoring (9.6%),
administrative cost of the Centre for diabetes care (7.8%) and emergency care (2.6%).
CONCLUSIONS
The evidence produced by the case study of ASL CN2 Alba-Bra in the Piedmont Italian region
represents the starting point to evaluate the cost-effectiveness of the diabetic pathway and to
select specific activities or technologies that can generate value for the patient and the society.
110

ROUTINE ASSESSMENT OF EFFECTIVENESS OF SECONDARY HEALTH CARE IN THE HELSINKI
UNIVERSITY HOSPITAL
Pirjo Räsänen1, Marja Blom2, Olli-Pekka Ryynänen3, Harri Sintonen2, Risto P. Roine1
1 Hospital District of Helsinki and Uusimaa, Helsinki, Finland, 2 University of Helsinki, Helsinki, Finland, 3 University of
Eastern Finland, Kuopio, Finland
CONTEXT
In efforts to ascertain that scarce resources are allocated in the most cost-effective way in
secondary health care, it is vital to be able to measure cost-effectiveness of routine care in ways
which allow commensurate comparison of costs and health gains of various treatment alternatives
across different diseases. Our aim was to test whether routine evaluation of cost-effectiveness of
secondary health care is feasible, to produce information concerning effectiveness for
administrative purposes, and to assess whether the obtained cost-effectiveness results are useful
for decision making.
METHODS
Since year 2002, patients entering routine treatment in several medical entities in the Helsinki and
Uusimaa Hospital District have been asked to fill in the 15D health-related quality of life (HRQoL)
questionnaire before and, depending on medical specialty, 3-24 months after treatment. The data
on effectiveness (perceived utility of treatment) thus collected are combined with direct medical
costs. These costs come from the hospital's official cost management system (Ecomed®) where all
costs of treatment of individual patients are routinely stored. The costs include those of inpatient
stays, outpatient visits, operations, radiology, pathology, and laboratory. The approach taken allows
the calculation of cost per quality-adjusted life year (QALY) produced by various treatments.
RESULTS
HRQoL differs at baseline among the disease groups, but improves as a result of treatment in most
of them. Some disease groups (e.g. depression with a mean (SD) baseline HRQoL score of 0.730
(0.212) show significantly (p

ALZHEIMER`S DISEASE - RESOURCE PROVIDING AND ECONOMICS FOR ENSURING CARE OF
PATIENTS IN PALLIATIVE MEDICINE
Ranko Stevanovic1, Lovorka Bilajac2, Ivan Pristas1, Irena Rojnic Palavra1, Vanesa Benkovic1
1 Croatian Society for Pharmacoeconomics and Health Economics, Zagreb, Croatia, 2 University of Rijeka School of
Medicine, Department of Social Medicine and Epidemiology, Rijeka, Croatia
CONTEXT
Present health economics results demonstrate that there is a significant amount of unnecessary
hospitalizations making patients spend too many days institutionalized and quite low quality and
lack of palliative care, whereas the numbers from secondary data analysis indicate that hospital
capacities and possibilities may provide high quality hospital palliative care. Aim was to
demonstrate possible ways of organizing and providing resources in palliative care of Alzheimer‟s
disease patients in Croatia, using health economics and supporting centre.
METHODS
Analysis of present hospital and other capacities, epidemiology, current health approaches,
recommendations based on real life and secondary data.
RESULTS
Results demonstrate that there is a significant amount of unnecessary hospitalizations making
patients spend too many days institutionalized and quite low quality and lack of palliative care,
whereas the numbers from secondary data analysis indicate that hospital capacities and
possibilities may provide high quality hospital palliative care. The research revealed numerous
potential sources of financing and providing resources for palliative care for Alzheimer`s disease
patients. Such are insurance companies (basic, additional, private) ; philanthropy and humanitarian
actions ; volunteers ; donations in money, services, drugs and goods ; taxes (state, county and city)
; foundations, real estate ; scientific, professional and marketing projects ; sponsorships, bank
loans etc. Unfortunately most of these sources are inadequately or totally unused or unrecognized.
CONCLUSIONS
Numerous organizational and direct health costs in Alzheimer`s disease palliative care come in
terminal disease phase, additionally burdening life of patients and their families: facility, overhead,
various services, insurance, material and drug, food, human labour (professionals and volunteers)
and transport costs. All of these indicate that palliative care should be based on a non profit model.
Such model should be supported by the work of a national centre for palliative care and network of
county centres, needed to gather, organize and provide resources for palliative care. It is necessary
to completely redesign organizational approach in Alzheimer`s disease palliative care. Such
redesign should be funded from various resources, whereas one national centre with counties
network for palliative care would efficiently organize and rearrange capacities, potentially help
acute hospitals, palliative hospices and carers in family and community, enabling higher quality in
care of terminal patients with less needed number of doctors and nurses.
112

IEMAC: A TOOL FOR GUIDING HEALTHCARE ORGANIZATIONS IN THEIR ANSWER TO
CHRONICITY
Roberto Nuño1, Nuria Toro1, Paloma Fernández-Cano2, Jose Joaquin Mira5, Olga Solas4, Joan Carlos Contel3
1 O+berri, Sondika, Spain, 2 MSD, Madrid, Spain, 3 ICS, Barcelona, Spain, 4 SESCAM, Toledo, Spain, 5 UMH, Elche, Spain
CONTEXT
Chronicity is a new concept that provides a better framework for understanding the implications of
chronic health conditions and polypathology for the affected persons, their families and caregivers,
and for health systems and societies. Chronicity urges to the need of redesign healthcare delivery.
As most provision of healthcare is oriented to chronic patients, we need to orientate health systems
to improve care delivery and organization. IEMAC is a tool designed to make operational the
conceptual framework of the Chronic Care Model (CCM) into a national (Spanish) health system
environment and guide improvement efforts.
METHODS
To make CCM operational into our health context, IEMAC has been developed by national experts
with successive different profiles of expertise using qualitative research techniques. A matrix was
built with the dimensions considered basic for the new model. Actions were identified and
categorized in each dimension, creating a taxonomy of components and interventions. Clarity,
appropriateness and degree of evidence were assessed for each intervention. The resulting
questionnaire was validated by other experts of diverse disciplines and scope. Finally, the
instrument IEMAC 1.0 has been piloted at macro, meso and micro levels.
RESULTS
IEMAC is a tool to be self-administered by health organizations at macro, meso and micro levels. It
is composed by 6 dimensions, 27 components and 80 interventions, whose implementation is
assessed with the aid of a scale which combines deployment, systematic evaluation and orientation
to improvement. IEMAC has a systemic, population-based approach and integrates promotion,
prevention and coordination with social care.
CONCLUSIONS
IEMAC shows a set of interventions which can be used as a road map by decision makers, managers
and clinicians interested in building a chronic care model of excellence. At the same time, IEMAC
allows health care organizations to know their baseline score and progress reached after
improvement interventions.
113

FOREIGN TRAINED DENTIST WORKING IN THE NETHERLANDS: MOTIVES AND MOVEMENTS IN
CROSS-BORDER BEHAVIOUR
Ronald Batenburg, Inge van der Lee, Phil Heiligers
NIVEL, Utrecht, The Netherlands
CONTEXT
The past decade globalization of markets and the development of free trade agreements have
driven cross-border movements and international mobility of health professionals. Dentist seems to
be one of the professions that are specifically willing and capable to work in different countries.
Previous research on European migration of dentists predominantly stems from the United
Kingdom. The cross-border mobility of dentists into the Netherlands is an interesting case as well,
as the foreign inflow has become substantial, and a national policy discussion has started about its
desirability in the context of a looming labour market shortage.
METHODS
Dentists with a non-Dutch residence and/or non-Dutch dentist diploma that registered themselves
are professional in the Netherlands between 2000 and 2010, were approached by mail and a
written questionnaire. Extra investments were done to trace the almost 1,500 dentists, as many
questionnaires were returned by the sender or the current resident. After a number of months 417
responses were collected, providing valuable information about the composition and motives of
dentists that worked, or did worked, in the Netherlands. Descriptive analyses are made of the
dentists by nationality and current employment. With regard to the workforce issue and discussion,
specific analysis is performed with regard to the length of their working career in the Netherlands,
as well as their working hours and position in dental practices. The profile of the foreign trained
dentists is statistically compared with Dutch dentists.
RESULTS
Most of the foreign trained dentists (68%) that responded were actually employed at the time of the
survey in the Netherlands. A substantial group however, has returned to their home country, some
(17%) without having worked in the country at all. Most hold a German (36%) of Belgium diploma
(23%). Those who left the Netherlands worked as a dentist for only 2 to 3 years. The dentists
currently employed in the Netherlands indicate that they expect to stay for a much longer period.
The migrated group is of relatively young age, while a remarkable high proportion of female
Belgium dentists responded. As what might not be expected, their average number of working
hours is lower compared to the Dutch dentists. Also, the expected age for remuneration of the
foreign-trained dentists is relative low (56) which confirms that only a minority is intended to
complete their career in the Netherlands.
CONCLUSIONS
Compared to other medical occupations, foreign trained dentists in the Netherlands are a relatively
large part of the current dental workforce. Based on this study it should be recognized however,
that they work significantly shorter and less hours as their Dutch-trained colleagues. This is an
important notion in relation to the current policy discussion on being self sufficient versus
recognizing the flexibility of foreign trained capacity inflow. Although this survey is the first insight
in this group of professionals that are hard to reach and monitor, many questions still remain to be
explored. Extended qualitative research is needed to discover the motives and attitudes of the
foreign trained dentists. Also, their behaviour should be studies in relation to the labour market
situation in their home countries. Finally, it is relevant to explore systematic differences between
dentists employed in border regions and those that actually migrated to the Netherlands.
114

EVALUATION OF TYROLEAN HOSPITALS TO OBTAIN THE ACCREDITATION
"SELBSTHILFEFREUNDLICHES KRANKENHAUS" (SUPPORT GROUP FRIENDLY HOSPITAL)
Vladan Antonovic (presented by Siegfried Walch)
Management Center Innsbruck, Innsbruck, Austria
CONTEXT
The self-help support groups play an important part in creating a communication bridge between
the hospital and the patients. This program forms the basis of an open communication platform,
where patients are able to openly exchange their experiences and to foster personal feedback.
Hospitals see this program as an opportunity to show their support and to become involved with
support groups through this initiative. MCI Innsbruck has come to an agreement with the umbrella
organization "Selbsthilfe Tirol" which oversees and coordinates all self-support groups in Tirol.
METHODS
MCI in association with the umbrella organization Selbsthilfe Tirol have created a catalogue of
standards and admission criteria which need to be fulfilled in order to be eligible to be awarded this
accreditation. The institutions must fulfil the following standards:
- Infrastructure
- Active Information
- Passive Information
- Cooperation between support groups and the hospital
- Press and Media
- Support Group Coordinator
- Interchange of Experiences
- Further Education on the topic of Support Groups
- Quality Management
- Agreement between the umbrella organization and the hospital
The hospital must firstly fill a self-evaluation form and that is then assessed directly through an onsite
visit of the commission. The commission is made up of members from the faculty of
International Health Care Management of MCI, the Tyrolean umbrella organization and local support
groups.
RESULTS
The main goal of cooperation between MCI Innsbruck and the umbrella organization is to monitor
the accreditation process of the hospitals which have an interest in obtaining this label.
CONCLUSIONS
The project will begin in March 2012 with the assessment of District Hospital of Lienz.
115

ACCESSIBILITY OF PRIMARY HEALTH CARE SERVICES IN URBAN COMMUNITY OF LITHUANIA
Skirmante Sauliune, Mindaugas Stankunas, Ramune Kalediene
Lithuanian University of Health Sciences, Kaunas, Lithuania
CONTEXT
World Health Organization calls all countries of the World to strengthen their primary health care
(PHC) systems to improve effectiveness, efficiency, equity, and sustainability of health care systems
(WHO, 2008). In the context of rapid development of PHC sector and establishment of private
structures, consumer satisfaction is an increasingly important issue in Lithuania. Therefore, the
objective of the study was to evaluate satisfaction with the accessibility of primary health care
services and factors associated with it among the Kaunas city (Lithuania) community members.
METHODS
A postal questionnaire survey was conducted during September-December 2010 in Kaunas city,
Lithuania. A representative random sample of 1600 adults aged 18 and above was composed from
the population register. The response rate was 45.5% (N=705). Questionnaire included questions on
general satisfaction with PHC services, evaluation of various communication aspects, and evaluation
of accessibility of health care services.
RESULTS
Majority of the respondents (561 or 81.1%) visited their family physician during last 12 months.
Satisfaction with the accessibility of PHC services was evaluated only for those respondents, who
visited their family physician during last 12 months. 362 (72.1%) respondents were generally
satisfied with the PHC services. The majority of respondents (79.4%) indicated that travel to their
doctor took half an hour or less and were satisfied (89.5%) with the access. 70% of the patients
waited for 30 minutes or less at their family physician's office, and 67.4% got to the physician at the
appointed time. One third of the respondents had the opportunity to contact their family physician
at any time of the day. Patients, who have chosen private PHC institutions, were more satisfied with
the accessibility of PHC than those, who selected public health care institutions.
CONCLUSIONS
In Lithuania, health care system reform emphasizes the importance of development of private PHC.
The implementation of the health care system with private independent contractors started in 1999.
In 2008, half of primary health care institutions were private. The results of this study indicate that
the majority of respondents were in favour with the accessibility of PHC services in Kaunas city,
Lithuania. However, respondents, who have chosen private PHC institutions, were more satisfied
with the accessibility of PHC. We can assume that the more positive evaluations about the private
PHC services were determined by the fact that the majority of the private PHC centres were
established during the last decade. Due to competitiveness with the other PHC institutions more
attention was paid to the organization of work, nice surroundings, the personnel's attentiveness,
and welcoming interaction.
116

PUBLIC-PRIVATE COOPERATION IN ORAL HEALTH CARE IN FINLAND
Anne Nordblad1, Elina Tuppurainen2, Pirkko Paavola2, Sari Mäki3, Taina Mäntyranta1
1 Ministry of Social Affairs and Health, Helsinki, Finland, 2 Social and health services, Jyväskylä, Finland, 3 Private
practitioner, Jyväskylä, Finland
CONTEXT
In Finland the public services are mainly funded by tax revenue. The public health care services are
supplemented by private services, which are partly reimbursed by the national social insurance. All
children are entitled to free care and adults pay fees of the oral health care services. In private
dental services, part of the treatment costs will be covered by health insurance. Private services are
more costly for patients. Odontologically necessary treatment must be provided in a reasonable
timeframe, within six months at the latest. Access to oral health care has been impaired by a lack of
dentists.
METHODS
The goals were closer cooperation between public and private oral health care, better support for
self-management and shorter the waiting times. In 2011 in the health care centre of Jyväskylä 4200
people were queuing to oral health care services more than six months. The waiting times for the
private services were between 2 - 4 weeks. In the pilot people in queue were informed about the
possibilities to choose private services and the principles of cost compensation. New legislation
offered same level costs for preventive and screening procedures in public and private sector.
Common grounds for oral health care were integrated covering the procedures of examination and
preventive measures. Totally 27 public dentists and 15 hygienists, and 14 private dentists and 8
private hygienists joined the pilot.
RESULTS
The persons who had been waiting for more than six months received information and 14% made a
decision to use private services. More letters are sent gradually. Preventive measures were bound
with the first oral health care visits and received more emphasis in the process of care. Closer
cooperation between public and private oral health care has been achieved. More time is needed in
order to verify results in shortening the waiting times.
CONCLUSIONS
The first results of the pilot are promising. The first results show that the pilot can be expanded
into other areas in Finland. Further research is needed to clarify the results on different levels and
processes.
117

THE NETWORK STRUCTURE OF NANOMEDICINE: EXPLORING THE ROLE OF HEALTH CARE
PROVIDERS
Americo Cicchetti, Valentina Iacopino, Daniele Mascia
Catholic University of the Sacred Heart, Rome, Italy
CONTEXT
Integration is a fundamental concept in health care, broadly used and studied to describe existing
links and coordination mechanisms between providers. However, there is scant knowledge about
forms of integration between health care providers and other organizations for what concerns
scientific knowledge production. Nanomedicine has been receiving increased attention by the
scientific community, especially in light of the role played by health care providers. This study
explores the role that health care providers play in the overall structure of collaborative network
relations in the nanomedicine sector.
METHODS
We identified actors and collaborative linkages in the nanomedicine sector in Italy through several
approaches. Firstly, we interviewed several opinion leaders in this field in order to reach
information about the evolution of the nanomedicine in Italy, in terms of factors affecting the
diffusion of the sector. In addition, we used secondary data. We firstly performed a systematic
review of published research papers querying the public database ISI Web of Knowledge. We also
identified Italian academic spin-offs and patents using ESPACENET Database. Finally, we reviewed all
the local, national and European research projects in which Italian actors were involved, together
with grants assigned to Italian researchers and educational programs activated. Social network
analysis techniques were used i) to identify the network structure of nanomedicine and ii) to
characterize the role of health care providers taking into account the various profiles of research
actors (public laboratories, pharmaceutical companies, academic spin-offs etc).
RESULTS
The principal output of this work is the provision of a detailed analysis of pathways and actors
involved in the nanomedicine field in Italy. Our findings indicate that health care organizations play
a fundamental, strategic role in this field. Individual actors network metrics have been adopted to
characterize the centrality of particular actors. Specifically, large teaching hospitals, research
hospitals (IRCCS) and public laboratories have a clear role as anchors and brokers in the overall
network. Whereas all widely involved in the co-authorship of publications and joint research
projects, we found a different propensity for health organizations to be involved in jointly
developed patents. Multidimensional analyses allowed us to identify relevant aggregations of
organizations in geographical boundaries, as well as to speculate about clustering and spillover
effects in this field.
CONCLUSIONS
Our study has important implications for policy makers, managers and hospital administrators.
First, policy makers in health care and other related fields may be interested to invest selectively in
specific geographical areas in which health care providers are prominent. Second, new companies
may be interested in localizing their research activities close to these actors, in light of the likely
spillovers documented in the present study. Finally, administrators may be aware that, more often
than they think, health organizations share collaborative relations with common third parties. This
information would be valuable for expanding trust and reciprocity from research activities to other
forms of collaboration regarding service provision.
118

THE PERFORMANCE EVALUATION OF POLICY NETWORKS IN THE INTEGRATED CARE:
CONNECTING THEORIES TO ORGANIZATIONAL PRAXIS. AN EXPERIMENTAL CASE STUDY
DEVELOPED IN A SPINAL UNIT OF LOMBARDIA REGION TO EVALUATE THE PERFORMANCE OF
POLICY NETWORKS MANAGING THE PATHWAY OF PERSONS WITH SPINAL CORD INJURY
Verdiana Morando1 ,2
1 Università Cattolica del Sacro Cuore, Milan,, Italy, 2 Fondazione ISTUD Business School, Stresa (Verbania), Italy
CONTEXT
The research project intends to develop a comprehensive performance framework for policy
networks that deliver public services, joining up the managerial with the evaluative approaches.
Moving from the increasing demand of performance since the NPM up today, a theoretical
framework has been designed to test its reliability towards a better use and understanding of
policies' performance against its paradoxes and limits emerged so far. The framework's value has
been applied and verified by an experimental case study focused on the integrated care policy
networks managing the pathway of persons with Spinal Cord Injury
METHODS
The consiliency has been exploited as an heuristic within the realistic evaluation
approach, coupled with the theories of complexity and the critical realism. This approach deals with
two problems: the complexity of the performance function and the need to join up the performance
management with the evaluation, when confronting with outcomes and with networking
organizations and actors. The framework is worked out based on four dimensions towards a
comprehensive assessment: values, regime, model and mechanisms (yet as knowledge processing
yet as causal explanations). This model leads the experimental case study design: the policy
network managing SCI patients is evaluated according to the three policy levels (from micro, Spinal
Unit and patients, to macro). The case study has been run through mixed methodologies (realistic
literature review, data collection, observational analysis, semi-structured interviews, questionnaires
and an organizational climate assessment) and employing analytical techniques (SNA, T-LAB, MOHQ
- Multidimensional Organizational Health Questionnaire).
RESULTS
At the theoretical level, the framework delivered a comprehensive performance evaluation of policy
network through its levels, detecting their mismatches. Where the organization resulted efficient
and efficacious, from an economic and clinical perspective, passing to the meso and then macro
levels the patients' pathway was ineffective, due to the lack of policy strategy and social services.
These limits were influencing contradictory outcomes of the Spinal Unit performance regime. The
inappropriate patients' journeys towards specialized units fostered these points. Secondly, at the
micro level, it emerged the efficiency and quality of a managed vertical network within the Spinal
Unit and its Hospital. The multi-professionals working team resulted highly required but difficult to
manage in practice due to professional-family resistances. The knowledge-processing mechanisms
resulted the vital clue to the performance. The patients' perspective confirmed the clinical quality
but highlighted lack of personalization with the rehabilitation and difficulties with long term care
management
119

CONCLUSIONS
The framework application was compelling. Future testing in different settings is required
(theoretical generalization) to value strength of dimensions identified and their implementation
across policies levels, whether a theory-led-evaluation may be successful to join up managerial
requirements and benchmarking measurements. The framework met its objectives, delivering a
deeper understanding of performance likely to a narrative. At the networking level, it synthesized
outcome and output measures confronted with different dimensions and stakeholders. The causal
mechanism distinguishes performance regime's influences from the operational model across three
levels. In the case study, it emerged the lack of a policy network able to manage the integrated,
health and social, pathway with direct and indirect impacts. The patient centeredness was more a
challenge than a practice: efficacy of integrated pathway is based on patient motivation and his/her
ego-network. The use of ICF classification to strengthen ties between social and health services
should be further evaluated.
120

INTEGRATED HEALTH CARE - AUSTRIA ON ITS WAY
Victoria Höß, Verena Stühlinger, Harald Stummer
UMIT - Health and Life Sciences University, Hall in Tirol, Austria
CONTEXT
An amendment to the Austrian law regulating all organizational aspects of hospitals (Austrian
Hospital Act - KAKuG) should help establishing integrated health care. Austrian hospitals will be
allowed to operate more on an ambulatory basis, as this is already the case in Germany.
Nevertheless, it must be taken into account that the Austrian health care sector is splitted. On the
one hand because of federal components and on the other hand due to a dual financing system in
health care (inpatient care paid by a pool; outpatient care sector directly by social health insurance).
METHODS
This work will analyse which impact the new amendment of the Austrian Hospital Act will have on
the coming forth of integrated health care in Austria. For this purpose, network analysis, critical
reviews, and legal analysis will be conducted to give an integrated insight into the reform. Besides,
a model reflecting the situation after the law will become effective will be designed. The focus of
the work lies on interdisciplinary analysis (economics and law), aiming at illustrating the impacts
this political decision will have on payers and health care providers.
RESULTS
Results show that there exist unsolved problems in the Austrian health care sector. As far as
hospitals are concerned, financing for the ambulatory sector is not based on DRG-related groups
but on lump-sums. Considering that some revolving door effect has already taken place since the
introduction of the current DRG-based prospective payment system in the inpatient care sector, this
effect might be intensified by the new system. A further increase of the importance of Austrian
hospitals that already account for around 40% of total health care spending is expected.
Furthermore, the model shows that there is hardly any incentive for hospitals to enhance their
cooperation with other health care providers. From the perspective of the social health insurance
the amendment is advantageous as it is expected that outpatient care is increasingly provided by
hospital ambulances and not by outpatient entities so that their payments might decrease for the
outpatient sector.
CONCLUSIONS
The results show that once again Austrian health policy is not approached by an integrated,
interdisciplinary way of thinking. This amendment of the Austrian Hospital Act will increase the
importance of hospitals that already at the moment accumulate debts. Even thought it might lead to
the possibility of acting more cost conscious, the authors miss a reflection on the system as a
whole. It is not yet discussed, which impacts there will be on the financing system, moving
payments from the outpatient sector financed by social health insurance to the inpatient sector paid
by a determined pool of taxes and social health insurance payments. There will be revolving door
effects until a DRG-based related system is introduced in ambulances as well. Although, the revised
law might be the right step to relieve chronically overburdened outpatient units, this step might
backfire as financing is the driving force for all players.
121

SENIORS' WILLINGNESS TO PARTICIPATE IN WORKING LIFE AFTER RETIREMENT
Minna Kaarakainen, Virva Hyttinen, Sanna Suomalainen, Sampsa Wulff, Markku Hänninen
University of Eastern Finland, Kuopio, Finland
CONTEXT
In this paper, we are focusing on the individuals' views on how they see their willingness to
participate in the working life in their senior years. Our focus is especially on welfare services,
because there is an urgent need for staff in the care sector in Finland. Aging is a Western-European
challenge now and in the future, especially in Finland. We assume that the participants in this
conference are aware of the aging challenges in general. In here, we are concerned with two sides
of this issue: qualified and aging human resources, and increased life expectancy.
METHODS
Policy studies have usually concentrated on the administrative and economic views, organizations,
policies, and professionals. They are seeking to solve labour shortage by using sticks and carrots.
At the moment, it is obvious that this is not always working. Our study is focused on the subjective
perspective: what is individuals' willingness to work in their senior years, and with what kind of
conditions. A quantitative questionnaire research was conducted in May 2011 by an internet panel
that consisted of 1011 citizens. The questionnaire was formed by focus group interviews from three
age-groups (n=30). The group was representative by respondents' age, area, income and gender.
Statistical methods were used for analyzing the results, such as the analysis of variance (ANOVA).
RESULTS
Quantitative data was representative by respondents' age, area, income and gender. According to
this data, it seems that men are more willing to continue working in their senior years than women.
On the other hand, women are more willing to work as volunteers than men. Political activity was
important, and there was statistically significant difference between age-groups. Older age-group is
more willing to participate in political activities.
CONCLUSIONS
From the individual's perspective, this means that they have more active years. In addition, overall
thinking of aging and seniors has changed: 60 is the new 40. In Finland, the central government
and policy programs are trying to keep people longer in the labour force. Citizens expressed strong
opposition to the plan. Although, our study revealed that individuals are willing to continue working
or doing volunteer work in their senior years. Nevertheless, there should be a freedom to choose
this option, and work with own terms, and not be forced by the politicians to do so. When we know
this reality, how to nudge individuals to work in their senior years?
122

COMPREHENSIVE ASSESSMENT OF PATIENT SAFETY IN MEDICAL ORGANIZATIONS OF THE
REPUBLIC OF KAZAKHSTAN
Vitaliy Koikov, Gulmira Derbissalina
Republican Centre for Health Development, Astana, Kazakhstan
CONTEXT
Over the past 20 years assessing patient safety issues considered as key to ensuring the quality of
care in the world. World Alliance for Patient Safety recommends to carry out strengthening of
patient safety in three complementary ways: prevention of adverse events and
their identification, mitigation of their effects in cases where they do occur. To achieve the highest
possible patient safety requires the combined efforts of patients, health policy makers and medical
practitioners. The aim of this research was to study the patient safety level in medical organizations
of the Republic of Kazakhstan.
METHODS
Methods of our research included comprehensive assessment of patient safety in health care,
identification of the factors contributing and impeding patient safety on the basis of expert
assessment of medical care, development of evidence-based recommendations for the
management of patient safety in health care. Methods of studying of the patient safety culture
included the views of patients and healthcare professionals about the factors that contribute to the
quality of medical services. The sample for the population sociological study – 7,001, a sample for
the medical workers sociological study – 4,999. Results of our research were processed by
statistical program JMP.
RESULTS
Expert assessment of medical care shows adverse effects of medical interventions due to violation
of the medical diagnostic process and as the result of actions of human factors (ethical), least of all
because of the state of resource provision. Expert assessment of the level of technical support and
population awareness shows that "dangerous" for the patient are the steps at the entrance to a
medical organization, inside medical organizations (slippery floors and stairs) and the lack of
sufficient awareness of the patients (information signs unpresentable and contain outdated
information). The results of sociological research have shown that patients often seek medical help
once in a year (33%) and 1 every six months (26%). Frequency analysis of the awareness of the
patient revealed that 71% of patients fully informed, while only 4% of patients low
informed. Percentage of satisfied patients was 58%, whereas the number of dissatisfied patients
was 42%.
CONCLUSIONS
Safety of health care requires efforts from all stakeholders - the health system (government,
medical organizations and medical professionals) on the one hand and patients on the other
hand. The main principles of the health system in providing safe care should be a quality of
care, timely response to disease, a high level of training of medical personnel, availability of
patients to the services of the health system, the continuity in the delivery of health services, the
use of medical technology with proven effectiveness. The main principles of the relationship of
patients to their own health should be a high commitment of patient to care, high motivation
to lead healthy lifestyles, shared responsibility of patients for their health.
123

PRACTICE EXAMPLE: STATUS QUO OF BACK-PAIN PATIENT'S CROSS-SECTORAL PATH OF
MEDICAL TREATMENT IN GERMANY
Wilfried von Eiff1, Alexandra Groth1, Samir Al-Hami2, Stefan Schüring1
1 CKM - Center for Hospital Management, Muenster, Germany, 2 Neuro Spine Center, Fulda, Germany
CONTEXT
Cost for health care increase every year in Germany. Reasons are the medical and technical
progress, demographic trends and an increasing number of patients with multimorbide and chronic
diseases. The demographic trend leads to a disparity between financial resources available and
needed to care adequately for patients. More elderly people in opposite to less young people,
paying for health insurance, face a problem for the financing of the health care system. The
available funds are rare and a path that is needed to be found in which the funds were used in the
most efficient way.
METHODS
Discontinuous cross-sectoral medical treatment is leading to negative medical and economic
effects. This should be illustrated by research of the current cross-sectoral path of back-pain
patients in Hessen, Germany. A discontinuous path through health care system means inefficient
usage of rare funds and a disadvantage for patients, passing through a discontinuous path of
medical treatment. The effects of the current path of patients on medical and economic factors are
demonstrated according to the way of back-pain patients with spinal surgery and subsequent outpatient
rehabilitation.
RESULTS
Patient's cross-sectoral way of medical treatment is characterized by double examinations resulting
from bad communication between medical actors and coordination of patient's medical treatment,
long waiting times for appointments, cycling times exceeding six month, unnecessary surgeries
because of bad inaccurate diagnosis, late diagnosis that extends cycling times and use of not yet or
not at all required therapies. Cycling times exceeding six month support risks for chronicity. This
will lead to, additional expenses for medical care, a health burden for patients and consequential
cost for economy. A way need to be found to prevent chronicity, support cross- and inner-sectoral
communication, to cut waiting and cycling times and use available funds in the most efficient way.
Integrated health care should be discussed to prevail chronicity, double examinations, an inefficient
use of funds, strengthen the communication, reduce unnecessary surgeries and ineffective
treatment.
CONCLUSIONS
This example shows that the trans-sectoral medical treatment of back-pain patients is in some
cases ineffective and inefficient and leads to negative effects on medical and economic factors. Risk
for chronicity could be reduced by the reduction of waiting times for appointments, double
examinations and indirections, definition of clearly defined medical pathways for back-pain
patients. Funds need to be used in the most efficient way; so that as many patients as possible
could be treated adequately and increases of health care insurance fees are not required. The
introduction of an integrated health care is one opportunity to overcome the current problems of
cross-sectoral treatment of back-pain patients and consequences of demographic trend. To prevent
waste of rare funds and to increase patient's outcome, the current discontinuous treatment process
needs a change that continuous cross-sectoral treatment is possible.
124

BURDEN OF MRSA - QUALITY, COSTS AND RISKS IN PATIENT CARE
Wilfried von Eiff, Dennis Haking
CKM - Center for Hospital Management, Muenster, Germany
CONTEXT
Annually there are approximately 500.000 nosocomial infections in Germany. Many of them are
caused by Staphylococcus aureus. Most critically are the risks for patients associated with
Methicillin-resistant Staphylococcus aureus (MRSA), because the antimicrobial therapy in this case is
limited. MRSA leads to prolonged and severe courses of disease, causing labour-intensive and
expensive consequences for the hospital due to complex hygienic measures and expensive
antibiotics. It has to be proven, that the costs of preventing MRSA in short term, as well as
considering the life cycle, are lower than the costs caused by MRSA-infection and -colonisation.
METHODS
High MRSA-rates are for hospitals with a high rate of foreign patients strategically and economically
problematic. This should be illustrated by the example of robotic-assisted prostatectomy in the
border area of Germany and the Netherlands. The Burden of MRSA is determined by the loss of
revenues for the German hospital and the disadvantage for the patients, who cannot be medicated
in the leading hospital in robotic-assisted prostatectomy, because Dutch insurance companies
might refuse to pay the medical treatment of their patients due to a high MRSA-rate in Germany.
The benefit of MRSA-prevention is demonstrated according to the German Diagnosis Related
Groups (G-DRGs), which bares weaknesses in financing innovative treatment methods.
RESULTS
Since 1992 laparoscopic radical surgery of cancerous prostate is established and advanced to the
robotic-assisted prostatectomy with many advantages in outcome like less blood loss or reduced
length of stay, compared to conventional methods. The additional costs of robotic assistance, which
are mainly determined by high costs of purchase and maintenance, are not compensated by the
German DRG system. One opportunity, to cover the costs, is to acquire foreign patients. This is
possible according to the German law Krankenhausentgeltgesetz (KHEntgG), which allows to
generate additional revenues by the treatment of foreign patients, preconditioned that the German
hospital reaches an agreement with the foreign health insurances. The Burden of MRSA results from
the migration of Dutch patients, because their treatment might not be paid anymore due to the
high MRSA-rate in Germany compared to The Netherlands, causing a financial loss for the hospital
in the amount of 1.6 Mio. Euros annually.
CONCLUSIONS
The previous example demonstrates the serious impact of an inefficient MRSA-management for the
single hospital, especially with dependency on foreign patients to finance innovative methods of
treatment. Thus the spread of MRSA has to be prevented and the amount of MRSA-positive patients
reduced, which leads to cost cutting in the inpatient sector. Infection-management has to be more
important in the certification of hospitals to get more impact on the decisions of hospital
managers. The prevention of infections is the central aspect of cross border patient care in the
EUREGIO and the basis for the economically attractive treatment of foreign patients. Networks, like
the EurSafety Health-net, want to improve the implementation of MRSA-prevention strategies by the
exchange of knowledge, technologies and cross border cooperation in the EUREGIO. The German
Robert Koch-Institute classified this network as the leading pilot project, which should be
implemented nationwide.
125

IMPACT OF HEALTH INSURANCE INSTITUTE FINANCING POLICY IN FINANCIAL AND
PERFORMANCE OUTCOME OF HEALTH CENTRES
Gazment Koduzi
National Association of Public Health of Albania, Tirana, Albania
CONTEXT
By 2007, Health Centres (HC) in primary health care are public entities, autonomous, contracted by
HII, financed according to package of services. HCcentre is managed by Manager and economist
that are responsible for financial and human resource. HC have bank account in order to do
financial payments. HC are financed performance based according to a new formula: 85% of budget
was given monthly for normal functioning of services, 10% was given monthly as performance
based (number of visits performed by a doctor per day) and 5% was called quality bonus, given
quarterly to HC.
METHODS
This study mean to measure impact of financial mechanism of HC in function of health staff
performance, by those components: Finances of health centres, health centres performance and
level of health staff knowledge about reform in selected health centres. Goal of the study is to
evaluate the impact of HII financial policy in framework of primary health care reform in
performance of health centres. This is a cross sectional study. Target of study are primary health
care centres, family doctors and nurse employed in selected health centres. Sampling 52 health
centres are selected randomly to be part of survey. Health staff interview was performed by using a
self-administered structured questionnaire. Data for financial and activity performance are taken by
HII database. Data analyses are done with SPSS program (19). Selected indicators were examined
against a set of variables using Chi-square and ANOVA test.
RESULTS
684 health staffs are interviewed by 52 HC, by which 17.3% were male and 82.7 % female and 42 %
work in urban area and 58% villages. Bonus level is increased almost 7% in year 2009 comparing
with year 2008 (p=0.07), meanwhile in year 2010 bonus is decreased almost 15% compared 2008
and almost 22% compared with 2009 (p

HEALTH MANAGEMENT OF CHRONIC OCCUPATIONAL DISEASES - A CHALLENGE FOR
BULGARIAN ECONOMY AND PUBLIC HEALTH
Karolina Lyubomirova, Nevena Tzacheva, Milena Yancheva, Lidia Hristova
Department Occupational Health, Faculty of public health, Medical university Sofia, Sofia, Bulgaria
CONTEXT
Nine percent of the Bulgarian population has permanent disability. Many of the people are victims
of occupational diseases which caused significant medical, social and economic losses. An
investigation of the prevalence of occupational diseases in Bulgaria for a 10 years period was
performed. The results showed increase in musculoskeletal diseases, diseases of the peripheral
nerves and non-specific respiratory diseases due to occupational risk factors. A new training
program for occupational health experts was introduced in the training of medical students which,
hopefully, will improve the level of early diagnostics, treatment and prevention of the occupational
diseases.
METHODS
Thorough collection of experts' decisions and registration carts of all patients with occupational
diseases in Bulgaria for the investigated period was done. Analysis of the health information with
determination of the workplace characteristics was performed. The prevalence and type of different
occupational diseases was determined and risk economic branches and work activities were
identified. Programs for training of bachelors, masters, post doc, PhD students and health and
safety experts were developed in Department Occupational health at the Medical University Sofia.
RESULTS
The result of the investigation showed that during the last 10 years (1998-2008) the prevalence of
occupational diseases in Bulgaria increased especially in some pathological groups. Musculoskeletal
diseases and diseases of the peripheral nerves due to occupational factors represent 55% of the
cases. Non-specific respiratory diseases (as chronic bronchitis, COPD, bronchiectasis) were 2%,
diseases caused by noise and vibrations were 12%. The total amount of people suffering from
occupational diseases in Bulgaria for 2008 (both employed and retired) was 32700 which were 17
per 1000 inhabitants. High portion of all non-specific respiratory diseases due to chronic bronchitis
(67%), COPP (23%) and bronchiectasis (9%). An ascending trend was registered which was due to
the high percent of risk occupational factors- common dust (45%), unhealthy microclimate (59%),
and chemical substances (29%) in numerous workplaces. The results for impaired workers' health
were confirmed by the data for the temporary work disability.
CONCLUSIONS
The number of people with permanent disability in Bulgaria is extremely high which is unacceptable
from social, medical and economic point of view. This is a result of the changed workforce
characteristics (aging population, migration), impaired working conditions during the transition
period and changes in health and safety policy, legislation and occupational health training of
medical experts. It is necessary to increase the quality of the occupational health training which will
accelerate the early diagnostics and prevention of the occupational diseases and will contribute to
improvement of the working conditions in the risky economic sectors. This process must be
facilitated by a better collaboration between the administrative bodies responsible for management
of the health and safety at work.
127