To the Editor:
Effectiveness in health-care management has been defined as the relationship between what a manager achieves in terms of performance and what he or she is expected to achieve; that is, effectiveness is the extent to and means by which an organization carries out its defined functions (6). The implicit, albeit core functions of hospitals and primary care centers in providing patient access, professional and center responsiveness, effective and safe services, and improved health outcomes, have increasingly been blurred by other more explicit objectives, such as cost-containment and process reengineering. Indiscriminate cost-cutting and “reengineering mania” have become popular among health-care policy-makers all over the world. Such strategies have even been adopted by countries (including Spain) whose health-care expenditures have for decades ranked below the European average (9). However, the effects of these widespread trends have never been properly assessed. They seem to impose a common threat on professional job satisfaction, and in Europe, there are more impatient patients on the waiting list than ever (8)
Given these pressures, why is the culture of assessment not yet an important ingredient in the social capital of health-care organizations? The members of the culture of assessment make critical thinking operational. This culture is part of an international, scientific, intellectual, and professional movement to encourage evidence-based decision-making in health care. Different labels are given to similar approaches in this movement, largely depending on sources of methodological specialization of the persons and groups involved. Hence, health services research (HSR), outcomes research (OR), health technology assessment (HTA), economic assessment, and evidence-based medicine (EBM), share similar conceptual bases and methodological tools to produce sound information for making better choices in health care (5). Critical attitudes and even critical skills are essential decision-making tools for recognizing valid information and protecting oneself from being seduced by rhetoric, indoctrinated by authority, or persuaded by enthusiasm.
Paradoxically, there are already a remarkable number of barriers and resistance to adopting a culture of assessment (4;10). Some managerial leaders often perceive the liaison between managers and researchers as useless, if not professionally dangerous. The underlying reasons for this attitude might be due a relative weight in the prevailing values held among the members of health-care organizations. These values may determine professional attitudes, which, in turn, inseparable from the corporate vision, influence executive decision making. These attitudes reflect a mainstream hierarchical construct where arbitrariness is an expression of power. In such a scenario, recommendations resulting from scientific evidence could contradict the opaque process of deliberation and its consequential decisions. In this case, the imposed culture is “obedience-based” rather than evidence-based. Furthermore, information coming from scientific evidence makes it difficult to practice medicine and management purely from obedience, or even to follow, without critics, the recommendation of charismatic leaders. In fact, a close relationship between health-care managers, clinicians, and researchers turns health-care organizations into learning (from assessment) organizations.
Nevertheless, a great array of values coexists in health-care organizations. Values will tend to imbue the atmosphere of a health corporation, rising and falling according to the influence of the people who hold them. Managers, clinicians, and researchers who are prone to organizational flexibility, that is, working in professional and scientific networks, are inclined to set priorities above and beyond cost-cutting. That sort of health professional prefers transparency in the process of decision-making and cooperation in planning as opposed to opacity and paternalism. Those managers, clinicians, and researchers who would prefer the former might consider the relationship between themselves helpful, even appealing. They could perceive a need to take advantage of transdisciplinary work to overcome a hazardous relationship rather than tolerating and perpetuating an environment of mutual mistrust, suspicion, and aspersed illegitimacy.
To encourage a productive liaison between management and the culture of assessment, initiatives are emerging at different levels of health-care systems all over the world (1;2). In Catalonia (Spain), the leaders of the Catalan Institute of Health (CIH) represent a new generation of managers, clinicians, and researchers who are trying to foster a better understanding of each other's aims. In managing health-care public resources, there are different ways to respond to similar challenges and to evolve from an infertile liaison that limits opportunities to an association that serves as a lever of modernization for outdated public health-care organizations. A brief summary of our experience with some initiatives undertaken at CIH could illustrate this point.
FRAMEWORK TO PROMOTE THE CULTURE OF ASSESSMENT IN CATALONIA (SPAIN)
The CIH is the largest health-care provider in Catalonia (Spain). It has a budget of approximately 1,800 million Euros and a staff of over 32,000. It includes eight “high-tech” teaching-hospital centers and over 450 primary care units. In 2001, a framework to forward the culture of assessment was created.
Members of the corporation agreed upon a strategic vision and a set of five explicit initiatives to foster the Culture of Assessment. These initiatives included (i) introducing clinical governance (CG), (ii) setting up a committee for evaluation of new approved drugs (CEND), (iii) defining the corporate quality standard for drug prescription (QSDP), (iv) disseminating clinical practice guidelines (CPG), and (v) establishing and agreeing on a new payment system for nurses and physicians both. Simultaneously, and crucial for implementing these initiatives, a heavy investment was made in information and communication systems and technology.
The CG initiative was designed as a tool to promote the continuous improvement of quality of care. It was based on the use of quantitative and qualitative information, such as patient and professional surveys of expectations and satisfaction. A formal contract agreement was signed between clinicians and managers of the corporation; this agreement was inspired by the results of the above-mentioned surveys. Thus, particular compromises were made in health-care process policies, including patient access to care, organization and professional responsiveness, clinician coresponsibility in the allocation of resources, and the use of evidence-based information in the implementation of specific corporate strategies. Over 100 contracts have been signed since the CG launching.
Likewise the CEND was structured to assess and disseminate (largely among GPs) evidence-based information related to approved-for-commercialization drugs. The fastest-growing component of Catalonian health-care spending is the introduction of new pharmaceutical drugs (centrally approved by the Spanish Ministry of Health in Madrid) into routine clinical practice. The CEND's comparative reports are available to all health professionals and the general population through the CIH corporate Web site (7).
Also through this Web site, sections pertaining to QSDP, an explicit set of quality indicators for drug prescriptions, are widely disseminated. This site allows clinicians to easily compare drugs and to use this information as a tool for quality self-assessment. The development, or adaptation and dissemination, of evidence-based “clinical practice guidelines,” edited in different versions for clinicians and patients, was another mainstay of this set of initiatives.
Finally, all these initiatives were monitored. Data were used for the first time in Spain as indicators for implementing economic incentives to health-care professionals by means of a new payment system agreed upon by the labor unions (3). The main features of this new payment system were two- fold. First, a variable payment was introduced as part of salary and was linked to the achievement of measurable and mutually agreed-upon annual objectives. Key criteria for the planned change included patients' accessibility to care; patient and professional satisfaction; professional and center responsiveness; program and service effectiveness and safety; the use of both evidence-based CPG; and the quality standard for improvement in prescribing drugs. This variable payment accounted for a maximum of 15 to 20 percent of the total salary.
The second feature of the new system was the design of a career development program for both physicians and nurses to formally address how to enhance professional skills such as means to access, analyze, and use health related research. Formal evaluation processes are in place to determine the effectiveness of these approaches.
The hypotheses for action at CIH were founded on the values alluded to previously as well as several principles, the first being the acknowledgment that, in this era of information-based society, management and assessment need each other badly. The second principle was the opportunity to begin building and developing a common agenda in certain areas, such as priority-setting for health services research, health technology assessment and outcomes research, methods development, impact assessment, and public involvement. The third and final principle upon which intended actions must be based is that transparency and accountability are imperatives for all actors in open societies and organizations. The overall aim is to foster a behavior change in managers, clinicians, and researchers alike such that the paradigm of participation and top-down transference of information is transformed into a paradigm of bidirectional transacting information, knowledge, and values.
These are some initial principles and hypotheses, a tentative agenda for actions in the field, which with the contributions of others, can shape a new picture for the future.
Dr. Alicia Granados served as President and CEO of the Catalan Institute of Health in Barcelona, Spain, from 2000 to 2003. As the director of the Catalan Agency for Health Technology Assessment and Research (1990–1999) and President of the International Society for Technology Assessment in Health Care (2001–2003), she has extensive experience in technology and services assessment.
The author wishes to express her gratitude to all members of the Catalan Institute of Health's executive committee during the period when these initiatives summarized in this letter were implemented: L. Fournies, P. Gallo, J. Gené, A. Gratacós, J. Navas, L. Sampietro-Colom, and J. Vilamasana. Thanks also to L. Colominas, C. Dominguez A. Gonzalez-Mestres, M. Martinez, and S. Papiol for their support.
