Management of Healthcare Processes Based on Measurement and Evaluation: Changing the Policy in an Italian Teaching Hospital

Background

The Ferrara University Hospital Trust is a public healthcare provider based at the “Sant’Anna” Hospital situated in the Emilia-Romagna region of northern Italy. It employs 2,628 members of staff, comprising 476 physicians, and trains graduate and post-graduate students from the affiliated University of Ferrara School of Medicine. The hospital itself houses 626 beds for inpatients and 85 for those receiving day-hospital care – in 2013 there were 19,406 admissions (excluding healthy newborns) and 7,029 day-hospital patients.

In the spring of 2001, the hospital performed a thorough self-audit, prompted by the sudden availability of theories and tools for self-assessment (EFQM, 1999a, 1999b). This process had its cultural background in 1997, when the Emilia-Romagna Regional Administration began putting together an accreditation system for healthcare structures and funding local Continuous Quality Improvement projects. It was also fuelled by the creation of new national databases to collect clinical data in various medical fields, namely the Joint Replacement Register, the ICU national database, the Heart Surgery Register (REAL), among others.