Health Care Organizations in Italy: Learning to Change

Introduction
For Italian healthcare organizations, the experience of Covid brought into sharp relief several organizational and operational issues. On the one hand, hospitals were praised for their effective reaction and rapid adaptation, but on the other hand, difficulties in coordination with other partners in the network were clearly revealed. The role of coordination played by Regional Authorities proved particularly critical. The pandemic showed up the need for change in the Italian health system in the direction of organizational effectiveness. But even without the pandemic, the National Health Service (NHS) was showing problems of sustainability, of a financial nature (management of the amount of resources allocated to health care) and particularly of an organizational nature.

It is therefore a priority for Italy to modify the way its health system is managed. The pandemic highlighted the following aspects:

• The motivation of staff is a key lever of quality and performance. The state of alarm generated by the pandemic in fact led to high-level performance from health workers across the country. But a state of emergency should be an exception, and there is a need to raise levels of motivation permanently in order to maintain quality and effectiveness in healthcare.

• The organization is bureaucratic and slow to innovate. Innovation in normal times occurs on the basis of legislation enacted by the Region, but the pandemic brought the principles of bureaucratic organization into question. Ideally, organizational processes need to empower staff at various organizational levels, and give more autonomy to employees.

• Organizational responsibilities are not always suitably rewarded, and systems that reward “loyalty,” compliance with the law and affiliations, often prevail. In order to reward responsibility, a system of performance measurement and evaluation is required. • Systems of monetary incentive in the public sector have in many cases failed, because of the shortage of resources and the absence of objective criteria in evaluation.

• Regional policies have sometimes discouraged innovation and experimentation in hospitals. Processes of innovation have been top-down, and decision-making centralized, in circumstances which in reality require decentralization and delegation.

• Although it is a crucial element in health care, there is a shortage of opportunities for professional development. Evaluation of clinical competence tends to be sporadic, and evaluation and measurement criteria are often inadequate.

The pandemic, however, brought opportunities for significant change, motivation and innovation, and it is extremely important for the NHS to build on these, as rapidly as possible, to continue to promote change and motivation.

The Covid-19 Experience: hospital organization
During the peak of the pandemic crisis in Italy (February-March 2020), a questionnaire was developed and administered to health management experts by Team Riforma of the University of Parma and Network Joint Commission International (forty Italian hospitals focused on quality through contents and methodologies of JCI). The aim of the questionnaire was to identify organizational problems and solutions in hospitals’ management of the pandemic. The Italian Network of Joint Commission International also recently promoted an award for projects developed by hospitals to respond to the Covid crisis, for which over 30 hospitals applied.

The following suggestions for improving hospitals emerged from these two projects:

• Logistics should be restructured. The logistics of many hospitals were severely tested because of lack of flexibility. Spaces need to be defined to distance Covid patients from other patients. Layouts need to be designed to adapt to specific trends in the demand, and allow for flexibility in the use of space and less rigidity in the allocation of beds. From an organizational point of view, the link between physical space and organizational unit needs to be weakened: the team must be able to operate in multiple places in the hospital.

• Coordination between the various organizational units, between staff, between hospitals and between the hospital and primary care must be strengthened. Creation of coordinator roles, regular meetings, and the use of information technology would be useful for this.

• Disaster planning with regular drills can help coordination during crises. During crises, mutual support and adaptation often come to the fore, but to better manage future crises, it is necessary to design and promote an organizational culture of coordination.

• Multi-professional and multidisciplinary integration must be significantly supported, and all professional profiles enhanced. Multi-professional teams are crucial, and hospitals should thus support task forces and teamwork.

In short, the pandemic has highlighted what type of intervention is necessary to increase organizational effectiveness, and these observations should be useful for guiding hospitals in the process. Regional authorities play a crucial role in promoting policies for change.

The Covid-19 Experience: primary care organization
During the first phase, the pandemic revealed certain issues in primary care to be particularly critical, albeit to varying degrees in different Regions. For a long time, healthcare personnel, including General Practitioners, professional associations, and trade unions and so on, had seen primary care as a problematic area of the NHS, mainly because of the scarcity of economic resources and skills, especially managerial. The pandemic only made these issues clearer.

The criticalities tend to be independent of the characteristics of the organizational model of each Region, but are linked instead to the functions assigned to primary care. The main problems affecting primary care are:

• the absence of timely information from health organizations;

• the absence of shared procedures and clinical pathways for the management of health emergencies;

• the different behaviors of professionals who thus do not provide a uniform response to patients.

Indeed, primary care in fact has often not received the right support at organizational or Regional level. Often there is little coordination between General Practitioners and other professionals, and few shared points of reference, and therefore outcomes are less successful. Poor organizational and operational flexibility can make responses less adequate across the board.

This all suggests that it is urgent to rethink the relationship between hospital and primary care. Hospital and primary care have always operated in Italy as a dual system, with little integration between the two. But the Covid-19 emergency has showed that this integration can no longer be postponed. There is an urgent need for tools to generate integration, or at least much closer coordination. Even where such tools already exist in the form of employment contracts, multidisciplinary teams and local health centers, they often need to be redesigned and strengthened.

Organizational theory has long pointed out that differentiation, indispensable for creating value, inevitably leads to different organizational cultures and possible areas of conflict.

The main area of conflict between primary care and hospital lies in the distribution of financial resources. There is widespread perception that hospitals have been better funded, and that primary care would need greater resources. But economic resources alone are not enough.

Primary care, in fact, requires greater support to improve preventive health measures, implement diagnosis and treatment processes, and adopt shared protocols. It urgently needs better organizational systems, coordination tools, and professionalism as well as higher levels of funding.

Coordination can be improved by redesigning operational tools and procedures, such as indications on guidelines and planning provided by management, evidence-based procedures, efficient information systems and teamwork on projects etc. Motivation levels of professionals are also a necessary condition for good coordination, but not a sufficient condition without adequate support.

The need for coordination of primary care is particularly amplified by at least three factors:

• General Practitioners, a key figure in primary care, tend to work independently: surely loneliness increases the need for coordination and does not favor the integration of skills;

• Nurses are present in some operational processes, but their responsibilities are not clearly defined and they have little professional autonomy;

• The geographic dispersion surely brings services closer to user but increases the need of coordination.

In practice, there is a need for institutional reform which allocates greater financial resources to primary care, and at the same time generates the conditions for better coordination and collaboration within the system.

Learning to change
Notably, the pandemic has highlighted that employees’ skills are a key aspect and that the right people must be selected for key roles. It is essential to reform the personnel selection, placement and evaluation system. A bureaucratic personnel management system, where compliance with the law is more important than performance, is not the best way to serve the public. Legislation should instead identify selection criteria valuing skills and competences, and support the use of valid performance measurement systems.

Organizational culture also needs to move towards supporting workers’ professionalism, while health professionals should be discouraged from perceiving their organization as a “bureaucratic machine.”

A heavily bureaucratic approach often goes hand in hand with an absence of trust and sense of responsibility. Today, it is necessary to increase health care staff sense of belonging for define team objectives and evaluate the results achieved. Projects have been found to be an effective way of developing skills of professionals and increasing levels of commitment, and it would be advisable for Regions to promote this way of working.

Another crucial issue is the coordination of care processes between professionals. Coordination is critical for both hospital processes and primary care processes, and also necessitates institutional reform. The elements to consider are:

• new professional roles, particularly nurses;

• new protocols and ways of coordinating General Practitioners with specialists in the health network, particularly hospitals;

• new technologies to facilitate the integration of General Practitioners, the hospital and primary care services for patients. Prompt updating of staff skills, and longer opening hours, are two ways in which the needs of the patients can be better met.

class="evid-arancio">The issue of professional evaluation is also important. When effectively conducted, it can help increase staff motivation levels and direct them towards pursuing the organization’s aims. Evaluation can generate trust and provide important feedback for triggering continuous improvement processes.

In conclusion, the Covid-19 pandemic has emphasized that hospitals today need to:

• assess performance;

• promote an organizational culture based on results;

• support the employees’ motivation; • support teamwork;

• put the patient at the center of attention (both in evaluation and in daily practice).