In recent decades, national health care systems have been dealing with an increased demand for high-quality and patient-centered services, but limited resources have often challenged their sustainability ([
1]). New demands and needs are emerging, connected with the growth of chronic pathologies, the ageing of the population, the development of technologies, the scarcity of economic resources and people’s emerging awareness of their care and cure rights. With respect to this demographic, epidemiological and social context, health care and hospital systems overall must innovate to respond to the new care needs. The mandate to “do more with less” encourages policy makers, health care managers and scholars to look for innovative ways to redesign health care services. The need for innovation is often interlaced with processes of organizational redesign in many forms. There are many examples of health care organizations that have committed to broad changes due to the actual social and economic demands. A significant stream of change relates to technological innovations, such as telemedicine ([
2]). There exists extensive experience of activation of new social and integrated care networks. These are designed to act as community-based care networks ([
3,
4]). A major movement in policy making identifies the “patient-centered approach” as the key leverage for making the health care delivery system respectful of, and responsive to, the current needs and requirements ([
5‐
8]). The patient-centered approach, while presenting clear statements, principles of care and operative practices, also leads to different care model designs within hospitals ([
9]). In fact, an increasing literature ([
10‐
13]) suggests that innovation in health care should evolve towards a patient-centered (henceforth PC) model, reshaping hospitals with the aim of moving from functional towards process-oriented organizational forms, focusing on the process of care instead of on functional, self-referential departments within the hospital. To innovate towards the PC model, hospitals usually undergo a process of redesign that encompasses several restructuring actions, both in the organizational structure and in the physical building ([
14]).
Although the theoretical managerial literature on the PC model is vast, evaluations of the performance of hospitals that have moved from the functional to the PC organizational structure are scarce (with a few exceptions, such as [
11,
15,
16]). The complexity of the variables at play, the sensitivity of data, which are not always made available for research, the diversity of the pathologies and types of patients and many other elements have so far made the construction of a methodological framework for the evaluation of the PC hospital model extremely challenging. The shift to different hospital models may therefore follow international trends and interests that not always are connect to clear
ex ante impact evaluation ([
17]). However, without any evaluative research, any innovation risks being perceived by local communities and by organizations’ employees as being driven more by political reasons or managerial trends than by a serious assessment of its benefits in terms of effectiveness and efficiency. In this work, we take the challenge to embark on a sound assessment of the efficiency and effectiveness of the PC model as opposed to the traditional functional-based hospital model. To approach the PC model evaluation, we begin by considering and evaluating two assertions that constitute the essential policy makers’ drivers for innovating towards the PC model:
Driven by the belief that an assessment of important organizational changes is crucial, we show how this is possible given the availability of a quasi-experiment and of adequate administrative data. Our research study focuses on the provision of health care services in the Lombardy region, the richest and one of the largest regions of Italy. With nearly 10 million inhabitants, Lombardy is larger than the median country in the EU by population and one of the richest region of Europe by per capita GDP. In this context, three important hospitals switched to the PC hospital model at the end of 2010, while the rest of the Lombardy hospitals remained with the traditional functional organizational structure. In this paper, we suggest an empirical strategy for a quantitative evaluation of the overall impact of the PC model on the pre-existing one, following traditional evaluation studies, in which the effects of a policy intervention are measured through appropriate econometric techniques (difference in difference estimators) on a set of selected outcome indicators (e.g. [
19]). The available data for this research, based on an administrative data set, are used to measure the effectiveness and efficiency by major diagnostic category (henceforth, MDC). The relevance of this study is related not solely to evaluate the PC hospital model impact, which is proposed as the main focus of our analysis. Our research exercise suggests that ex-post assessment of organizational changes by the use of statistical data is relevant for informing about policy implications and serve as a driver for future innovations.
The patient-centered hospital model
Hospitals have often been conceived as functional organizational structures, in which patients requiring a similar area of expertise are grouped into independently controlled departments. Although in some countries such organization seemed for a long time to be the most appropriate to support and foster the knowledge development required by medical science, the functional structure has shown severe shortcomings, consisting mainly of economic and organizational inefficiencies. In fact, the functional organization often lacks the capability to control the work flow across departments and thus the coordination of the care activities within a patient care trajectory. Moreover, in the functional organization, resources tend to be duplicated, causing waste, and the autonomy in using the specialty’s resources often prevails over accountability, in some cases reducing the effectiveness of treatments ([
10,
12,
20]). The inefficiencies and complexities detected in functional hospital organization led to many forms of organizational innovation. Examples may be found in the process-oriented design ([
11,
20]), in the lean philosophy ([
21]) or in the experimentation of new hospital settings ([
9]). Another planned change process is the one defined as the patient-centered (PC) hospital model, towards which hospitals are converging worldwide, for instance in England ([
22]), the Netherlands ([
23]), Spain ([
24]), Sweden ([
25]) and Italy ([
26]). The PC model represents an attempt to redesign the care delivery process by shaping the structures and processes involved in delivering hospital care according to the needs of the patients. In the traditional hospital models, patients are admitted under individual specialist clinicians, who keep them or transfer them to the care of another clinician.
As summarized in Table
1, to innovate toward the PC model, hospitals undergo a process of redesign that encompasses several restructuring actions that, by taking stock from authors (cfr. [
10,
20,
27]) we summarize over six dimensions ([
28]). The first regards the change of the organizational model, which passes from a functional/divisional model to a process-oriented model ([
20]). The second is the transformation of the concept of organizational unit, necessary for responding to patients’ care needs and for managing the relationship among specialties. The criteria for patients’ allocation to hospital units switch from specialty-based units to multi-specialty units, differentiated by the level of patients’ clinical and assistential care needs instead of by their specific pathologies. In fact, the core principle of the PC model consists of the delivery of the appropriate amount of cure and care to patients in the most suitable setting according to their health conditions. Third, as the PC model requires integrated care, multi-professional and multi-specialty teams are strengthened and requested to collaborate. This is consistent with a different analysis proposed for patient centeredness carried out by [
29] and by [
30]. An example of this new integrated effort is represented by the specific reconfiguration of nurses’ position, in which the traditional “functional nursing” (i.e. nurses specializing in a single care activity) becomes “modular nursing” (i.e. nurses responsible for the overall assistential practices required by small groups of patients within the ward). Fourth, hospitals rethink their use of resources, such as beds, operating rooms and equipment, which are shared by all the functional specialties and they, regroup and regulate them by a centralized logistical model. Patients are no longer transferred across different units or departments; rather, physicians and technologies move to the patients’ bed. Fifth, such re-organization calls for new managerial roles ([
10]) responsible for the appropriateness, timeliness, flow and integration of patients’ care delivery process (e.g. the bed manager or case manager). Sixth, the described changes might require a redesign of the physical environment to maximize the resource pooling and the patients’ grouping based on the patients’ clinical severity and on the complexity of the assistance required ([
27]).
Table 1
Disentangling the differences between traditional and PC hospitals
| Functional hospital configuration | More recent innovations: converging patterns towards PC hospitals |
Organizational model/ care delivery model | Functional/divisional model | Lean organization/process-oriented model |
Organizational unit: patients’ care needs and the relationship among specialties | Specialty-based units. Practitioners (doctors and nurses) are grouped into semi-autonomous units depending on their specialty of belonging | Multi-specialty units. Units are aggregated in accordance with patients’ clinical and assistential needs. Doctors might treat patients located in different units and nurses might assist patients with different pathologies |
Model of care | Functional nursing (nurses’ task-oriented job: each nurse is specialized in a single care activity) | Modular nursing (nurses are responsible for the overall assistential practices required by small groups of patients within the ward) |
Use of resources | Separated resources (beds, operating rooms, equipment, nursing staff, other staff) devoted to the individual specialties | Resource pooling: resources are shared by all the functional specialties regrouped |
Managerial roles | Head physicians in charge of their departments | Bed manager/case manager (as distinguished by the clinical activity) for centralized operation management |
Physical environment | Hospitals are built around fixed and focused spaces, with often isolated wings | Newly built hospitals are designed to maximize resource pooling and patient grouping, flexibility and modularity of spaces |
The PC organizational model is understandably characterized by local variations depending on the boards’ strategic choices, the hospitals’ dimensions, the workforce composition, the patients’ average characteristics, and so on. While this type of diversity is hardly predictable and should be better addressed by case study analyses ([
31,
32]), the main common traits of the PC innovation can be identified, provided that a suitable environment and adequate data are available. For the former, one needs a context in which, from a pool of comparable units before treatment, some hospitals have been treated while others have not. For the latter, one needs data characterized by minimal error due to mis-measurement, a non-random response rate and proper population coverage. Unsurprisingly, there are very few studies providing ex post analysis of the implementation of the PC model so far. The application of the PC principles is expected to improve quality, increase patient satisfaction, increase job satisfaction for staff and improve efficiency ([
33]). Reports on new PC - hospitals highlight the positive aspects of patient-friendly and staff-friendly design ([
34]). Other authors, however, question the strength of these claims ([
18,
22]). A few authors (see for example [
10,
20]) present extensive literature reviews on assessing hospitals’ changes and hospital designs (see for example [
35]), thus ending up tracing the factors that affect their success or failure in the redesign process but provide no ex post analysis of the PC model adoption. To the best of our knowledge, there is still little evidence either to support or to refute these claims, notably in the European context ([
36]), and there is no quantitative assessment of the efficiency and effectiveness of the PC model as a whole. Considering the relevance of the PC model change with respect to hospital managing and policy making, and considering also the extensive implementation and debate in European countries and international context, this paper proposes to fill the quantitative assessment gap, with a specific focus on efficiency and effectiveness of PC implementation.