16 de des. 2018

10 years of The Catalan Institute for the Evaluation of Public Policies (Ivàlua)

The Catalan Institute for the Evaluation of Public Policies (Ivàlua) was created 10 years ago. It's a public institution depending of the Government of Catalonia. The board of trustees is made up of the founding Academic Institutions (UPF), public institutions (Ministry of the Vice-presidency and of the Economy and Finance, DIBA, CTESC, CIC)

Ivalua promotes the evaluation of public policies among the Catalan public administrations, non-profit entities that pursue objectives that are of public interest and among citizens in general,

The evaluation is a tool for improving government performance and democratic accountability. To accomplish its mission, Ivàlua is guided by the following strategic lines:
  • Evaluation of public policies and advisory activities
  • Training and generation of training resources
  • Promotion and dissemination of evaluation
Ivàlua has traditionally and naturally specialised in social policies, employment policies and educational policies (in this field jointly with Fundació Jaume Bofill they are promoting the #WhatWorks in Education movement)

All the activities done during these 10 years have been done with Independence, Technical Rigor to generate evidence and with maximum Transparency at all times. In their website you can download all the Evaluations carried.


photo: Ivalua Team; Marc Balaguer, Mireia Climent, Núria Comas, Marçal Farré, Laura Kirchner, Jordi Miras. Erika Pérez, Ramon Sabes-Figuera, Jordi Sanz, Anna Segura, Federico Todeschini, Frederic Udina.

22 de nov. 2018

think big... or better not: what the evidence says to hospitals' scale?

One important source of potential inefficiency in the hospital sector relates to hospitals’ scale and scope.
  • Big Hospitals: It might make good economic sense to enlarge the size and scope of a hospital to make better use of available expertise, infrastructure and equipment. However, at some point, a hospital departs from its optimal level of efficiency and begins to exhibit diseconomies of scale. Bigger organizations are harder to manage.
  • Small Hospitals: At the other end of the scale, small hospitals might also be inefficient because the fixed infrastructural and administrative costs are shared across too small a caseload, thereby pushing up the cost of an average hospital visit.
Monica Giancotti, Annamaria Guglielmo, and Marianna Mauro did a huge systematic review from the last 50 years (1964-2014) of research "published in peer-reviewed scientific journals" to try to answer some of these questions:
  • Have mergers contributed to enhance hospitals efficiency?
  • Which is the optimal size of hospitals in terms of beds?
  • Which factors influenced the hospitals scale efficiency?
According to the evidence the main conclusions are:
  1. Studies analysed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals
  2. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200–300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.
  3. There is no evidence that the increase in size may lead to outcome improvements.
  4. Teaching activities are an important cost-driving factor,
  5. Hospitals that have a broader range of specialization are relatively more costly.
  6. According to ownership, public hospitals are more efficiently than other types.
  7. According to location, urban hospitals used resources more efficiently.
Access to the Article (free): (2017) Hospital Size: Systematic Review

photo: 1957. Chicago The LIFE Picture Collection

30 de set. 2018

public sector responsiveness

Despite the recent increase of empirical research and conceptual development in transparency and accountability this has been on the side of citizen action, looking at why and how citizens mobilise around accountability demands and at what makes their actions successful.

Comparatively, there has been much less work exploring the state side of the equation – to explain why and how public officials respond (or not) to citizen demands for accountability.

The research brief from Anuradha Joshi, Rhiannon McCluskey Why and how bureaucrats respond to citizen voice (2018) review the relevant literature on public sector responsiveness and they try to answer the other side of the equation.

Their main conclusions are:

Whether public officials respond to citizen demands depends on several sources of pressure upon them including organisational, professional, elites and citizens. With respect to citizens, the key to whether demands translate into effective pressure is the way in which public officials perceive citizens and their claims:
  • The legitimacy of their claims. Regarding legitimacy, there is a higher likelihood of eliciting responsiveness from public officials if claims relate to existing entitlements in law or policy, as well as if claims are broad and inclusive, rather than narrow.
  • The credibility of who makes the claims. Ensuring that civil society organisations are neutral in respect to political parties might strengthen their credibility. Also, the degree to which they genuinely represent marginalised groups allows for perceptive public officials to take them more seriously.
  • The level of trust between public officials and citizens. Engagement with citizens can transform public officials’ perceptions of citizens’ claims and their legitimacy. Through repeated interactions that demonstrate integrity, they can earn each other’s trust. If this trust exists, public officials will be more willing to ‘stick their neck out’ for citizens.
photo: (*) Photosolde Tanqueu totes les portes

25 de jul. 2018

Back to basics: the 7 enemies of evidence-based policy

Evidence-based policy is focused on research-based evidence to inform policymakers about “what works” and thereby produce better policy outcomes.

Graham Leicester in his 20th century article - 1999- brings us a number of factors that he suggests inhibits the adoption of the evidence based policy

What we could do against them?
  1. Recognise that these enemies are everywhere not only in the governing machine. In the universities, research centres, ... 
  2. We live in a risk society and the whole society is a laboratory. All the things that happen are real life experiences with risky technologies, not experiments conducted in laboratory controlled conditions. That means that when they go wrong—and it is axiomatic in the scientific model that they must go wrong if progress is to be made—they do so for real. There needs to be a much closer relationship therefore between government and research evidence. 
  3. The political management of the evidence in our ‘risk society’ is even more important than the evidence itself. Researches have an obligation not only to be as rigorous as possible, but also to recognise that their research has a political dimension. What they choose to investigate, how and when they present the findings are part of the risk management process. They are all agents of change.
  4. Technological advance is giving a new opportunities to get to grips with complexity. The increase in processing capacity makes all sorts of things possible in the management of complex systems. There is now a capacity for instant information gathering and analysis which makes all policy into a continuous real-time experiment. The researcher’s role will be to monitor, evaluate and adjust continuously. 
  5. We must work harder to develop better data, and true indicators of what really matters to us as a society. We need data that answers the question ‘why’ as well as ‘how much’ or ‘how many’? We need indicators which can stand proxy for the general health of society, measures of the vital signs.
It is important for researchers not only to gather the evidence to describe what is happening and how society is changing, but to provide explanations about why these changes are occurring, and then ideally to suggest things that might be done to adjust the system accordingly.

As a Citizens we want evidence-based policy NOT "policy-based evidence": where evidence is typically used as a weapon — mangled and used selectively in order to claim that it supports a politician’s predetermined position

Acces to the article (restricted): The seven enemies (1999)

photo: Game of Thrones. Jon Snow: You know nothing and Book

27 de maig 2018

are you free to speak up in your team?

I would like to show you “Freedom to Speak Up”, the review chaired by Sir Robert Francis QC. The purpose of the review published in 2015 was to provide independent advice and recommendations on creating a more open and honest reporting culture in the NHS.

The review followed on from the Public Inquiry, also chaired by Sir Robert, into the Mid Staffordshire NHS Foundation Trust which exposed unacceptable levels of patient care and a staff culture that deterred staff from raising concerns.

The 20 principles to create “an open and honest reporting culture in the NHS were:
  1. Culture of safety: Every organisation involved in providing NHS health care, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns.
  2. Culture of raising concerns: Raising concerns should be part of the normal routine business of any well-led NHS organisation.
  3. Culture free from bullying: Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. 
  4. Culture of visible leadership: All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. 
  5. Culture of valuing staff: Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. 
  6. Culture of reflective practice: There should be opportunities for all staff to engage in regular reflection of concerns in their work. 
  7. Raising and reporting concerns: All NHS organisations should have structures to facilitate both informal and formal raising and resolution of concerns. 
  8. Investigations: When a formal concern has been raised, there should be prompt, swift, proportionate, fair and blame-free investigations to establish the facts. 
  9. Mediation and dispute resolution: Consideration should be given at an early stage to the use of expert interventions to resolve conflicts, rebuild trust or support staff who have raised concerns. 
  10. Training: Every member of staff should receive training in their organisation’s approach to raising concerns and in receiving and acting on them. 
  11. Support: All NHS organisations should ensure that there is a range of persons to whom concerns can be reported easily and without formality. They should also provide staff who raise concerns with ready access to mentoring, advocacy, advice and counselling.  
  12. Support to find alternative employment in the NHS: Where a NHS worker who has raised a concern cannot, as a result, continue in their current employment, the NHS should fulfil its moral obligation to offer support. 
  13. Transparency: All NHS organisations should be transparent in the way they exercise their responsibilities in relation to the raising of concerns, including the use of settlement agreements. 
  14. Accountability: Everyone should expect to be held accountable for adopting fair, honest and open behaviours and practices when raising or receiving and handling concerns. There should be personal and organisational accountability for:  a) poor practice in relation to encouraging the raising of concerns and responding to them; b) the victimisation of workers for making public interest disclosures; c) raising false concerns in bad faith or for personal benefit; d) acting with disrespect or other unreasonable behaviour when raising or responding to concerns; e) inappropriate use of confidentiality clauses.
  15. External Review: There should be an Independent National Officer (INO) resourced jointly by national systems regulators and oversight bodies and authorised by them to carry out the functions described in this Report, namely: a) review the handling of concerns raised by NHS workers and/or the treatment of the person or people who spoke up, where there is cause for believing that this has not been in accordance with good practice; b) advise NHS organisations to take appropriate action where they have failed to follow good practice, or advise the relevant systems regulator to make a direction to that effect; c) act as a support for Freedom to Speak Up Guardians;provide national leadership on issues relating to raising concerns by NHS workers; d) offer guidance on good practice about handling concerns;publish reports on the activities of this office.
  16. Coordinated Regulatory Action: There should be coordinated action by national systems and professional regulators to enhance the protection of NHS workers making protected disclosures and of the public interest in the proper handling of concerns.
  17. Recognition of organisations: Care Quality Commission (CQC) should recognise NHS organisations which show they have adopted and apply good practice in the support and protection of workers who raise concerns. 
  18. Students and Trainees: All principles in this report should be applied with necessary adaptations to education and training settings for students and trainees working towards a career in healthcare. 
  19. Primary Care: All principles in this report should apply with necessary adaptations in primary care.
  20. Legal protection should be enhanced 
Acces to the report: Freedom to Speak up
National Guardians Office: Web Access

photo: (*) Photosolde.
Lita Cabellut

6 de maig 2018

breaking the hospital model

The hospitals have to move from the concept of “repair shop” function to a "hub" in their community: providing social services, improving education and becoming aware of their significant economic role in communities. Hospitals have the potential to affect the economic model and the social determinants of health by leveraging their hiring, purchasing, investing, and other operational assets more intentionally.
  • HUB means an organization or institution that is a focal point in a community and helps blend together a range of stakeholders and services that improve the health and economic mobility of residents. It does not necessarily lead activities or function as the sole focal point—often it is a partner with other institutions. But through partnerships and its own services it enables organizations and people with particular skills, assets, and connections to work more effectively together to improve the neighborhood.
Some recomendations to promote a Hub:

Improve the collection, use, and sharing of data among sectors to facilitate partnerships. Hospitals as data warehouses centers for the community, assuring interoperability and data governance including detailed demographic data, and other information to build a picture of the community.

Make greater use of intermediaries. Hospitals, are often seen by many community organizations as remote yet powerful institutions, and a lack of trust arising from little or no history of partnerships. Hospitals has to build trust inside their community. Intermediaries are organizations or individuals that provide specialized skills or “connecting” functions that facilitate partnerships,

Widen the skill sets of hospital leaders and key staff. Train the leaders and the staff. The full potential of hospitals as hubs requires leaders in these institutions to have a broad vision and set of skills, to manage the delivery of less traditional services, and to work with partners and intermediaries.

Essay and error

Government has to increase the promotion of the pilot projects and programs in different communities and encourage the impact evaluation. Also, they should give more flexibility in the hospital's payment systems being less oriented to outputs and more to outcomes. Take steps to facilitate the braiding and blending of public and private resources from multiple sectors and sources.

Access to the article: Hospitals and Schools as a Hubs (2016)
Authors: Stuart Butler and Carmen Diaz

photo: Third and Colectivo Rua