Hospital companies, like all companies, work well or badly depending on how they are managed. With one difference though: the former manage health and management errors are not allowed. The news usually tell us exceptional cases such as: «Molinette, 5-year-old girl saved with a liver transplant connected directly to the heart» (December 11, 2022); «Gemelli Polyclinic, a case of rare complexity: in the same session, a coronary bypass was performed, a kidney tumor was removed and a huge thrombus was removed. Engage 3 teams for 10 hours» (February 10, 2023); “Padua, transplanted a heart stopped for 20 minutes: first time” (May 15, 2023). A deserved and reassuring clamor. At the same time there are episodes of medical malpractice that make just as much noise and terrify us. The daily life we usually deal with as patients is, however, mainly made up of something else: emergency room, waiting lists, diagnostic tests which, to be precise, must be performed with machines under 10 years of age. And it is here that, with rare exceptions, the quality of care and the ability of managers are closely linked. Let’s see what it means.
When a hospital works well
A hospital works well when it meets essential requirements:
1) and Emergency room where patients do not leave because they have not received the necessary care and assistance within 8 hours;
2) waiting times that comply with the provisions of the law (e.g. hip replacement surgery within 180 days and breast, colorectal and lung cancer surgery within 30 days);
3) low rates of hospitalizations at high risk of inappropriateness (such as arthrodesis), hospitalization of patients in the right ward for their problem (for example, as few hospitalizations of medical patients as possible in surgical wards), not allowing too many days to pass from hospital entry for surgery to surgery itself ability to attract patients from outside the Region;
4) budgets and accounts in order;
5) nadequate number of doctors and nurses per bed;
6) non-obsolete machinery and equipment.
Report cards to general managers
On the basis of these indicators, for the first time, it is possible to give a report card on how public hospitals are managed: Agenas, the National Agency for Regional Health Services which belongs to the Ministry of Health, evaluated the performance of manager of 53 public hospitals, 30 of which are university hospitals, divided respectively into those with more than 700 beds or fewer than 700 beds. It did so as required by the 2019 Budget law which entrusts it with the task of monitoring the achievement of the objectives of the general managers: «Agenas – reads in art. 1, paragraph 513 – implements (…) a system for analyzing and monitoring the performance of healthcare companies which signals, in advance, through a special alert mechanism, any significant deviations relating to the economic-managerial, organisational, financial and accounting components , clinical-assistance, clinical efficacy and diagnostic-therapeutic processes, quality, safety and outcome of care, as well as fairness and transparency of processes”. Excluding the non-university Irccs, the mono-specialists, the local health authorities and local companies such as the local health and social care companies (Asst) of Lombardy which since 2015 have incorporated almost all the public hospitals in Lombardy: the decision to exclude them by Agenas is motivated by the need to have comparable data. The results that you will read below have been cross-referenced with the data of the «National Outcomes Plan», the tool with which Agenas annually tests the quality of care, confirming the correspondence between the managers’ skills and clinical-care results.
Top 9 hospitals
Here’s what the results of the first report presented in Rome yesterday, May 24, 2023 say (the data are available on the portal created on the subject by Agenas at this link). 2021 was taken into consideration, the year in which hospitals still had to deal heavily with Covid (in the graphics all the results also for 2019 which, in the absence of the pandemic, see higher performances). Of the 53 hospitals examined, 12 have a low level of performance, 32 medium and only 9 high which are: the university hospitals of Siena (Siena), Careggi (Florence); Pisana (Pisa), Padua, Integrata Verona and Policlinico Sant’Orsola (Bologna); and the hospitals of S. Croce and Carle (Cuneo), Riuniti Marche Nord and Ordine Mauriziano (Turin).
The 12 red dot hospitals
The hospitals with the lowest performance are: Cosenza, San Pio (Benevento), Sant’Anna and San Sebastiano (Caserta), Riuniti Villa Sofia Cervello (Palermo) Civico Di Cristina Benfratelli Hospitals (Palermo), Cannizzaro (Catania), San Giovanni Addolorata (Rome), San Camillo Forlanini (Rome); and university students: Luigi Vanvitelli (Naples), San Giovanni di Dio Ruggi d’Aragona (Salerno), Mater Domini (Catanzaro) and Policlinico Umberto I (Rome).
Waiting times for cancer surgery
These are the 10 hospitals with the shortest waiting times for cancer surgery (here the official document): Senese, Padova, Pisana, Policlinico Umberto I Roma, Careggi, S. Croce and Carle, Integrata Verona, Policlinico Sant’Orsola, Riuniti Foggia, Sant’Andrea di Roma which, however, is indicated as low quality for colon surgery. And these, instead, are the 10 hospitals with the longest waiting times for cancer operations: SS. Antonio and Biagio and Cesare Arrigo (Alessandria), San Luigi Gonzaga (Turin), Sant’Anna and San Sebastiano (Caserta), Ospedali Riuniti Bianchi Melacrino Morelli (Reggio Calabria), Policlinico Monserrato (Cagliari), For the Emergency Cannizzaro (Catania ), Sassari university hospital and finally: Giaccone (Palermo), Pugliese and Mater Domini (Catanzaro) where the wait is long, but then the levels of care are good.
More or less obsolete machinery
The 10 hospitals with least obsolete equipment are (here the official document): Policlinico San Martino (Genoa), Riuniti (Foggia), Policlinico Sant’Orsola (Bologna), Maggiore della Carità (Novara), S. Croce e Carle (Cuneo), San Pio (Benevento), Sant’Andrea (Rome), Cardarelli and Monaldi Dei Colli (Naples), San Giuseppe Moscati di (Avellino). The last three in Campania which, evidently, has made investments to renew the machinery, even if the three hospitals still have poor levels of cancer treatment. Hospitals, on the other hand, with more obsolete equipment – and an old machine is always less accurate than a new one –: University Hospital of Cagliari, Riuniti Villa Sofia Cervello (Palermo), Papardo (Messina), Per l’Emergenza Cannizzaro (Catania), University Hospital of Sassari, Brotzu (Cagliari ), Civico di Cristina Benfratelli (Palermo) and, surprisingly, there are also three listed hospitals in this list: Mater Domini (Catanzaro), Senese and Policlinico San Matteo in Pavia.
Duration of hospitalization with the same severity
Then there is an indicator (which is technically called «Comparative Performance Index») which allows the duration of hospitalization to be assessed for the same severity of the case (here the official document): the longer it is, the more it means that the hospital has organizational problems. The best: Riuniti Marche Nord, Careggi, Pisana, Pugliese, Maggiore della Carità. The worst: S. Giovanni Di Dio Ruggi D’Aragona (Salerno), San Luigi Gonzaga (Orbassano), Civico Di Cristina Benfratelli (Palermo), Cardarelli (Naples), Umberto I (Rome).
Political responsibilities
With all due exceptions, these results are evidence of the organizational and resource management skills, or otherwise, of the general manager. For example, Agenas data shows that on average a hospital operating room performs only 400 operations a year, which means little more than one a day: similar performances in other companies would never be accepted. How are the general managers chosen and by whom for public hospitals? Since 2012, Regions can only appoint general directors registered in the national register. Requirements: Bachelor’s degree, 5 years’ proven management experience in the healthcare sector or 7 in others, attended a public health training course and be under 65 years of age. Then there are also the commissions of experts who evaluate, but in the end the one who deals the cards is the president of the Region in agreement with his health councilor. The choice is therefore political.