Introduction
Methods
Context
-
directly managed acute care and rehabilitation hospitals provide hospital-based acute inpatient, outpatient, and rehabilitation care;
-
health districts are sub-ASL geographical units responsible for coordinating and providing primary care, non-hospital-based specialist medicine, and residential and semi-residential care to their assigned populations; district physicians provide home care services, drug abuse prevention services, and care for terminal AIDS patients;
-
health promotion divisions are responsible for promoting health and preventing infectious and other diseases in the community; these divisions also provide services for monitoring environmental hazards, preventing occupational injuries, and supervising the production, distribution and consumption of food and beverages.
-
ASL divisions are organized as departments and run by healthcare professionals, who must have the clinical and managerial expertise needed to provide the health services, design an annual plan of activities, and allocate the resources obtained by means of negotiations with the ASL’s general manager, consistently with regional and local plans and service programs. A department’s activities are programmed, implemented, and monitored with the active participation of health professionals assigned to the department.
Survey design
Health system governance framework design
Results
I n = 94 (%) | II n = 41 (%) | III n = 52 (%) | IV n = 112 (%) |
P value | |
---|---|---|---|---|---|
Public health issues never or almost never covered by ongoing training experience | |||||
Health service programming | 55.43 | 24.39 | 32.69 | 25.89 | <0.001 |
Mass media communication | 50.00 | 36.59 | 26.92 | 35.71 | 0.037 |
Communication with policy-makers | 60.87 | 46.34 | 40.38 | 44.64 | 0.053 |
Complex adaptive system management | 47.83 | 34.15 | 19.23 | 24.11 | <0.001 |
Leadership | 57.61 | 36.59 | 38.46 | 38.39 | 0.019 |
Human resource management | 53.26 | 41.46 | 42.31 | 33.04 | 0.037 |
Inequality-reducing strategies | 57.61 | 41.46 | 51.92 | 50.89 | 0.386 |
Issues on which no further training is needed | |||||
Health economics | 7.61 | 2.44 | 7.69 | 16.07 | 0.046 |
Health service programming | 6.52 | 4.88 | 0.00 | 13.39 | 0.018 |
Mass media communication | 6.52 | 4.88 | 3.85 | 9.82 | 0.484 |
Communication with policy-makers | 6.52 | 2.44 | 1.92 | 10.71 | 0.114 |
Leadership | 5.43 | 4.88 | 3.85 | 17.86 | 0.004 |
Human resource management | 6.52 | 2.44 | 3.85 | 12.50 | 0.091 |
Inequality-reducing strategies | 6.52 | 9.76 | 7.69 | 21.43 | 0.006 |
Subjects | Roles | Functions |
---|---|---|
Regional health directorate, LHU (local health unit) manager | Strategic planning—regional and local levels | Defining principles/values Assessing health needs Establishing priority goals/health policies |
Operational planning—local level | Establishing strategic objectives and initiatives | |
System leadership role—local level | Devising policies and goals in cooperation with the Regional health department Negotiating budget/extras tailored to achieve objectives Coordinating health services Approving budget and monitoring expenditure Managing community relationships Managing relations with private accredited providers (based on regional and local health goals) Managing personnel and other human resources Managing support services Managing communications | |
Governance of particular health services | ||
Level I subjects: structure manager, e.g. of acute care and rehabilitation hospitals, health districts, health promotions | Cooperating on planning Service programming Service planning Service leadership role | Negotiating goals for services Defining and monitoring services programs Defining and monitoring operational services projects Resource programming Cooperating with other health care structures Personnel management Process management Cost management |
Level II subjects: health service manager, e.g. as head of hospital or district, or prevention service | Cooperating on programming and planning | Designing and monitoring operational projects |
Health service leadership role | Cooperating with other services | |
Work management | Personnel management Process management Cost management Assessing production processes |
Function | Activities | Competency |
---|---|---|
Defining principles/values | Adopt National Health System principles Community values assessment Define the principles for organizing health care providers and for providing health care services | Understand NHS principles and current public health issues, and engage in systemic changes to address them Understand relevant but competing values that are perceived to be legitimate and fair Understand relevance to the local setting, decided on the strength of shared criteria; publicize priority-setting decisions and the reasons behind them Provide leadership to ensure that the above conditions are met |
Assessing health needs Establishing priority goals/health policies | Identify expressed and unexpressed needs | Use epidemiological, qualitative, and comparative methods to describe the health problems of a populationa
Identify inequalities in health service provision and access Establish priorities for the most effective use of resources Understand the benefits achievable with health care or wider social and environmental changes Have a practical understanding of what is involved, the time and resources needed to undertake assessments, and ensure sufficient integration of the results in the planning and commissioning of local services |
Identify the importance of a need in terms of frequency or severity, the evidence of the efficacy of interventions, or the feasibility of change (from social, health and economic perspectives) Define criteria coherent with principles to prioritize needs Involve other organizations such as social services, local authorities, volunteer groups, etc.… in the process of defining priorities | ||
Defining health objectives | Establish priorities/value-laden choices/address a broader range of relevant values, such as trust, equity, accountability and fairness that are of concern to other partners and, not least, to the populations concerned Model effective group process behavior including listening, exchanging opinions, negotiating, rewarding, encouraging, and motivating | |
Establishing strategic objectives and initiatives | Analyze relationships between needs, and the supply and demand of services, to ascertain met and unmet needs Involve other organizations such as social services, local authorities, volunteer groups, etc.… (adopting principles and priorities defined by strategic planners) Establish strategic objectives and initiatives, together with financial and organizational criteria for managing health care organizations (based on objectives and principles defined by strategic planners) | Epidemiological and economic analysis: conduct the analysis in the same way as for any good or service, but bear in mind that it has peculiar features that may mean that the usual assumptions on the effects of markets on resource allocation do not hold Epidemiological and economic analysis: judge the degree to which scarce resources are employed according to two main criteria: efficiency and equity Translate broad strategies into practical terms for others; build alliances, partnerships, and coalitions to improve the health of the community or population being served; identify and engage stakeholders in interdisciplinary projects to improve public health Monitor efficiency, effectiveness and appropriateness Understand the attribution or contribution of observed results to a program; define new policies and programs that respond to these challenges |
Program assessment | Design assessments so that they reflect a program’s stage of development, define the purpose of the assessment, its uses, and the questions to be answered | |
Devising policies and goals in cooperation with the regional health department | Legislation provides the general manager with substantial autonomy in managing human, financial and technological resources. This autonomy is expressed in: A three-year strategic plan in which the general manager defines the organization’s mission and goals, which should be consistent with the regional health plan An annual strategic program in which the general manager defines annual projects that contribute to achieving the objective in the plan | Make strategic decisions based on recognized values, priorities and resources Identify and communicate new system structures as needs are identified and opportunities arise Ensure that organizational practices are aligned with changes in the public health system and the larger social, political, and economic environment |
Negotiating budget/extras tailored to achieve objectives | Negotiate global budget (ASL services are financed under a global budget) Negotiate additional funding (for purchasing technologies/building works/…) | Demonstrate the ability to interpret and explain financial and managerial accounting information, prepare and analyze budgets, and make sound financial management decisions |
Coordinating health services | Define objectives for health services Ensure that financial resources are committed to those activities that contribute to organizational goals (budget allocation for health services) Develop and manage shared projects (define objectives, support for and supervision of Functional Departments) | Enable health services to create, communicate and apply shared visions, missions and values Contribute to developing key values and a shared vision in planning and implementing programs Build on capacity: improve performance and enhance the quality of the working environment Contribute to maintaining the organizational performance standards of health services Demonstrate an ability to build on the capacity of health services by sharing knowledge, tools, expertise and experience and resources Enable health services to share a patient-centered vision of health care |
Program assessment | Demonstrate the ability to monitor the program’s stages of development, and to identify and remove obstacles to the achievement of the objectives | |
Approving budget and monitoring expenditure | Re-direct resources, reorganize health services to maximize the impact of healthcare on health needs Make carefully considered strategic decisions to ensure that health services are stable and sustainable into the future Financial management and cost control | Assess the costs and benefits of shifting resources, Identify different expenditure patterns, explain them to the population at large, and engage the public more meaningfully in decisions on future spending patterns. Demonstrate the ability to draw up plans for outlays and incomes based on history and an understanding of what the future holds Make decisions on resource allocation, and contribute to the effectiveness of the health care system |
Managing community relationships | Manage relations with politicians Manage relations with citizens | Create and communicate a shared vision for the future and inspire the community to achieve it Translate broad strategies into practical terms for others Build alliances, partnerships, and coalitions to improve the health of the community or population being served Identify and engage stakeholders in interdisciplinary projects to improve public health Advocate and participate in public health policy initiatives at local, national and/or international levels |
Managing relations with private accredited providers (based on regional and local health goals) | Define types of service to have supplied by private accredited providers on the grounds of unmet needs Negotiate the volume of services and financing with private providers Systematically monitor the volume and quality of services supplied by private providers | Demonstrate the ability to negotiate with private accredited providers for services to be supplied |
Managing personnel and other human resources | Conduct job analyses Plan personnel needs and recruitment Select the right people for the job Career orientation and training Provide benefits and incentives Assess performance Solve disputes Communicate with all employees at all levels | Advocate for learning opportunities within the organization Create and communicate a shared vision for the future and inspire team members to achieve it Encourage others to have a sense of ownership of the public health mission in the organization Help others to clarify their ideas, create consensus, and develop ideas into practicable plans Offer opportunities for collaborative learning and quality improvement Develop and mentor potential future leaders within the organization |
Managing support services | Define aims and tasks for support services Monitor and assess support services Plan, monitor, and assess outsourcing | Create and communicate shared aims for health and support services Engage support services in interdisciplinary projects to improve public health Identify activities to outsource and the entity of these activities; communicate the reasons for outsourcing them |
Managing communications | Health communication Risk communication | Demonstrate the ability to develop communication strategies, design internal and external communication directives, and manage the flow of information Demonstrate the ability to ensure that the logic, outcomes, significance, and limitations of the risk assessment are clearly understood by all stakeholders |
Function | Activities | Competency |
---|---|---|
Negotiating goals for services | Adopt general health objectives (based on regional and local planning) Propose health objectives, based on regional and local values and principles, for future planning in order to deal with unmet needs | Use evidence- and research-based health policies and programs |
Defining and monitoring service programs | Propose program objectives consistent with regional and local plans Give local managers feedback on the progress of the program (timetable/resources/intermediate and final objectives) | Analyze information to identify appropriate implications, uses, gaps and limitations Establish the meaning of information, considering the current ethical, political, scientific, socio-cultural and economic contexts Recommend specific actions based on the analysis of information |
Defining and monitoring operational service projects | Suggest project objectives consistent with regional and local plans and service programs Define operational objectives Define strategies/timetables/resources/intermediate and final objectives Define guidelines and protocols Define outcome and process indicators Assess operational projects Give local managers feedback on the progress of projects (timetable/resources/intermediate and final objectives) | Describe program options chosen to address a specific public health issue Describe the implications of each option Develop a program for taking action bearing in mind relevant evidence, legislation, emergency planning procedures, regulations and policies Implement a program to address a specific public health issue Demonstrate the ability to coordinate the process for implementing good practice guidelines Assess an action or program Demonstrate the ability to establish and follow priorities, and to maximize outcomes based on available resources |
Resource programming | Suggest budget objectives consistent with service objectives to local managers | Demonstrate the ability to translate health objectives into service objectives |
Promoting personnel to achieve defined objectives | Negotiate training aims with personnel Propose training consistent with objectives of regional and local plans and service program | Be aware that the staff is the most valuable asset in any business |
Cooperating with other services | Cooperate with local manager and other services on the management of shared actions Cooperate with support services | Cooperate to optimize performance by sharing resources and responsibilities Use skills such as team building, negotiation, conflict management and group facilitation to build partnerships |
Personnel management | Assess the need for human resources to achieve service goals Assess the skills of human resources Allocate human resources Guarantee personnel safety Define individual and group objectives for personnel Assess personnel based on their achievement of individual and group objectives Cooperate with local manager and personnel office | Describe the mission and priorities of the public health organization where you work, and apply them in practice Contribute to developing key values and a shared vision in planning and implementing public health programs Contribute to team and organizational learning in order to advance public health goals Demonstrate the ability to build team spirit by sharing knowledge, tools, expertise and experience |
Process management | Process monitoring: define process indicators Adopt surveillance systems (care associated infections, clinical risks) Quality/efficacy/patient safety monitoring: define outcome indicators | Contribute to maintaining organizational performance standards |
Cost management | Monitor the achievement of budget objectives Monitor the use of resources | Demonstrate the ability to manage resources |
Function | Activities | Competency |
---|---|---|
Designing and monitoring operational projects | Adopt objectives of local plans and service programs and propose operational programs to Department Directors Propose operational objectives Propose specific strategies/processes/timetable/resources needed Propose guidelines and protocols Propose outcome and process indicators Collect data for operational project assessments Give Department Director feedback on progress of operational projects (timetable/resources/intermediate and final objectives) | Develop projects for taking action bearing in mind relevant evidence, legislation, emergency planning procedures, regulations and policies Implement a project and/or take appropriate action to address a specific public health issue Demonstrate the ability to implement good practice guidelines Demonstrate the ability to keep to priorities, and to maximize outcomes based on available resources |
Cooperating with other services | Cooperate with other services and units on the management of shared actions | Cooperate to optimize performance by sharing resources and responsibilities |
Personnel management | Assess the need for human resources to achieve the unit’s goals Assign personnel tasks and responsibilities Ensure personnel safety Define individual and group objectives for personnel Assess personnel based on their achievement of individual and group objectives Manage available spaces and working patterns | Recognize staff’s talents and skills Give personnel opportunities to learn and do new things Give personnel feedback on their performance to help them improve their performance and enhance work efficiency Use skills such as team building, negotiation, conflict management and group facilitation Understand and adopt principles and of appropriateness, efficiency, humanization, equity… Understand the needs of individuals, the needs of teams, the needs of the organization/patient groups |
Process management | Define production processes consistent with objectives and in accordance with principles of appropriateness, efficiency, humanization, equity… Monitor budget objectives related to process management | Implement, coordinate and monitor production processes to address specific service objectives |
Cost management | Monitor usage of resources | Demonstrate the ability to manage resources |
Assessing production processes | Give Department Director data for use in process assessments Discuss the achievement of objectives with personnel and identify areas needing improvement | Assess an action or program Analyze information to identify appropriate implications, uses, gaps and limitations |