At the heart of the establishment of the HSE Integrated Services Directorate is a performance contract which defines expectations regarding deliverables by the regional teams, writes Conor Hannaway.
The recent reorganisation of the HSE and, in particular, the establishment of the Integrated Services Directorate, is designed to enhance the efficacy, efficiency and cost of patient services. Taken alone, few organisational restructurings are successful or achieve their potential if they consist only of changing reporting relationships.
To make a real difference, restructuring must be part of a comprehensive programme of organisational renewal which may include clarifying responsibilities and accountability, up-grading systems and processes, rationalisation of activities and the development of supporting mechanisms such as data management and ICT capability.
The Integrated Services Directorate in the HSE has embarked on an ambitious programme of change which includes a number of initiatives to align organisational processes within the new structure.
At the heart of the initiatives is a performance contract which defines expectations regarding deliverables by the regional teams within the ISD. It provides a set of incentives for successful performance against specific objectives and puts in place a corrective action process for dealing with situations where performance falls below expectations. It is interesting to see what lessons can be learned from the use of incentives in other jurisdictions.
One of the most striking demonstrations of the power of incentives comes from the US where results are available from a major research programme which has been underway since 2003. In this research, top performing hospitals receive financial bonuses based on their performance on evidence-based quality measures for inpatients with conditions such as heart attack, pneumonia, coronary artery bypass graft, and hip and knee replacements. The quality measures recorded are validated through independent research.
The Shore-Long Island Jewish Health System North was one of the earliest participants in the programme. It manages a group of 14 hospitals and nearly 5,000 beds serving five million people on Long Island and in New York City. Its workforce of 38,000 employees prides itself on high-quality care and patient satisfaction. By agreeing to take part in the programme, it accepted a challenging set of 30 measures to assess the treatment of thousands of patients. For example, heart attack victims had to receive aspirin within two hours of arrival, beta-blockers at discharge and be given smoking-cessation counselling.
One of the most striking demonstrations of the power of incentives comes from the US where results are available from a major research programme which has been underway since 2003
The hospital group was successful in achieving additional funding by meeting and exceeding the targets. Its North Shore’s chief medical officer, Lawrence Smith testified to the favourable outcomes from a patient care perspective when he spoke to the US House of Representatives Ways and Means Committee in 2009. “If all hospitals nationally were to achieve the (study’s) three-year mortality improvements across the project’s five clinical areas, 70,000 lives per year could be saved.” He also pointed out that national healthcare costs in the US could be reduced by $4.5 billion annually.
There are costs involved in introducing the system which is highly data intensive and requires a considerable administrative burden. Implementation of such a programme needs also to be advised by sensitivity to unfavourable and unintended outcomes that sometimes follow the introduction of incentive programmes. Research from the UK, such as that conducted in 2008 by the Imperial College Faculty of Medicine, is consistent with the findings of the research in the US. However, other research points to the problems of incentivising performance where systemic issues militate against desired performance outcomes.
Overall, the research strongly endorses the use of performance contracts within the HSE. They have significant potential to promote change and to incentivise performance improvements. It would be useful to validate the effectiveness of implementing them in Ireland and to monitor any side-effects associated with their usage.
Conor Hannaway firstname.lastname@example.org