Introduction

Healthcare organizations today are facing a series of problems due to two main factors: increasing difficulty in satisfying a progressively more ‘aware’ and demanding user, and the need to change their internal organization to keep pace with the very rapid changes taking place in technology and approach. A continuous increase of complexity and the capacity of physicians will not ensure the fundamental requirement of any business: to really deliver what its customers need. Hence, it is time for a revolutionary strategy focused on: (i) maximizing value for patients by obtaining the best outcomes at lowest cost and (ii) moving from a physician-centred organization to an ‘organization-driven’ care process.

However, complex systems are typically conservative and rather resistant to change, and the healthcare system is no exception to this rule. The challenge is that doctors have to be central players in the healthcare revolution and any strategy that they do not embrace will fail. Certainly, a piecemeal approach will not work. Engaging doctors in transforming the system requires focusing on shared goals, by using motivational tools: shared purpose, peer pressure, measuring performance, and enhancing a patient-centred approach.

GVM Care & Research is a holding operating in the health, pharmaceutical, spa-well-being, research, biomedical industry, company-aimed services, real estate, and financial areas. The core business is the network of highly multi-specialized hospitals and day-hospital outpatient clinics: this complex system, involving specialized facilities and highly qualified professional expertise, is present in numerous Italian regions and extends also to France, Albania, and Poland. GVM is one of the key players in Italy in cardiac surgery (responsible for ∼15% of all cardiac interventions in Italy) and interventional cardiology, with documented excellent outcomes (cf. the Italian National Healthcare Agency and Italian Ministry of Health).

Defining the plan: mission, vision, and goals

The first step in any strategic transformation is to clarify the institutional mission, visions, and goals. The ‘mission’ declares the organization's distinctive purpose or reason for being. The vision represents what its leaders want the organization to achieve when it is accomplishing the mission. Strategic goals are those overarching end results that the organization pursues to accomplish its mission.1–4 GVM's cardiovascular mission in the past was: ‘Improve the health and well-being of patients through effective approaches to the diagnosis and treatment of cardiovascular diseases and their prevention mediated by innovative clinical research’. The strategy for moving now to a high-value healthcare organization comprises five variables: (i) designing and implementing a corporate organization dedicated to cardiovascular patients, including new clinical governance rules; (ii) driving the changes by work volume and performance, in a single matrix; (iii) increasing innovation in clinical processes and implementing clinical research as a structural component of clinical procedures; (iv) expanding geographic networking; and (v) developing an advanced information technology (IT) platform5 (Figure 1).

Figure 1

The GVM value agenda.

Figure 1

The GVM value agenda.

The task of building a vision for an organization is frequently referred to as ‘path-finding’. The goal of the pathfinder is to provide a vision, find the paths that the organization should propose in the long run and mark the trail for those who will follow.6–10 To effectively outline the future and facilitate the pursuit of organizational excellence, visions need to be translated into ‘action plans', considering:

  1. primary targets, i.e. sectors to be sustained, expanded, or reduced;

  2. external context analysis, e.g. the presence and type of competitors, geographic and demographic data, the network and relations, and international connections;

  3. internal context analysis, i.e. expertise, mindset and attitude of the heart team, structure, organization, quantity and quality of production (database), and periodic monitoring of the database and processes;

  4. strategic targets, e.g. teamwork, performance improvement, increased number of patients referred, innovative techniques, inpatient clinics plan (GVM point program), innovation and production in clinical research, and presence and competitiveness in Europe.

Organizational culture

To successfully implement the strategy, a change in ‘organizational culture’ is required. Although cultural change is difficult, it is often an important factor in moving the healthcare system toward realizing its strategy. An organizational culture is the consciousness of the organization that guides the behaviour of individuals; it may be founded on shared purpose, value, and behavioural norms. The GVM organization was created by a bottom-up approach with shared assumptions including a common understanding of ‘who we are’ and ‘what we are trying to accomplish’. Certainly, we shared values such as a common understanding of ‘GVM doing things'. Parallel to its cultural change now, GVM has adopted a new organizational structure in order to facilitate the implementation of the overall strategy11–20 (Figure 2).

Figure 2

Organizational structure of GVM.

Figure 2

Organizational structure of GVM.

Clinical program, performance, and reporting to drive improvement

The healthcare future will be based on larger and integrated systems, patient-centred care, a new relationship between hospitals and physicians, and a shift of many inpatient procedures to outpatient or home settings.21–32 Since the biggest driver of rising costs is medical progress and procedural improvements that generate a fragmented and disorganized system, in order to create a common language, GVM has defined guidelines for a strategic plan focusing on high-quality, medically excellent procedures, innovative techniques, participation in international networks, and scientific publications.

Organizational culture requires rigorous measurements of value: namely, outcomes and costs. Accordingly, we introduced the GVM performance index, composed of the key indicators of clinical activity, approach and results pertaining to the single hospital and its surrounding area (GVM Area, see geographic network). Measuring a full set of outcomes that matter is indispensable to better meeting patients' needs. At each single level, variables (hence indexes) were grouped into four macro-areas (Table 3): (i) clinical indexes, (ii) program index, (iii) economic indexes, and (iv) reputation index (Figure 3).

Figure 3

GVM area and hospital score indexes.

Figure 3

GVM area and hospital score indexes.

Area performances, as well as the medical team performances, should be computed on the basis of the ability of both areas and teams to reach the established targets. This approach has made possible a greater integration of production and performance data, finally available within a single matrix and, hence, more sensitive and able to describe the Group's positioning and capability, both horizontally (in a given time, between different hospitals), and vertically (in a given hospital, across different moments). Monitoring has been applied, both at single-hospital level, at hub-and-spoke area level, and at medical team level (entire network within a given medical area).

For some of the variables comprised in the above-mentioned indexes, a given numeric threshold was identified and set (in coherence with recent regulations, i.e. the ‘Balduzzi’ law), while in other cases the threshold was set at a value equal or better than GVM's average performance. Financial incentives were used in GVM in the past but they were not sufficient to optimize doctors' performance. Since comparing outcomes is complicated, we have implemented coordination, information sharing and team work as performance measures.33–43

These systematic measurements of results and the periodic activity of reporting outcomes using peer pressure have produced significant improvement in quality of care, outcomes and costs in GVM and have positively influenced several important indicators in the cardiovascular area: As far as the area indexes are concerned, there was a clear improvement in all areas considered. Results from the Cardiac Surgery and Cardiology Hospital Score indices are also very interesting: measuring the Cardiac Surgery index, six hospitals of nine improved their performance, one showed no difference, while only two showed a lower score, due to external reimbursement regulations.

  1. the volume of cardiovascular surgical procedures performed by GVM in 2013 rose by ∼10%, inverting the negative trend of the previous 3 years;

  2. the average length of hospital stay in cardiac surgery decreased in 2013 by about half a day compared with the same period in the previous year;

  3. cardiac surgery mortality decreased significantly, by 1%, in the same period;

  4. endovascular cardiology increased by ∼1% in 2013 with respect to 2012.

Clinical research

Scientific research is a necessary component of a healthcare institution working in areas where culture, technology, and clinical care processes move quickly and need continuous updating, first so as to keep abreast of intellectual advances, secondly so as to be part of the community of experts able to discern the quality of the new proposals and disentangle true novelties from cosmetic changes, thirdly so as to be able to contribute to the advances and play a role in their management. Clinical research should not be a corollary in the strategic planning of health management, but rather it should be a primary component in the array of mid- to long-term goals, and also part of the investment plan.

The structure and planning of the scientific activity of the GVM network is coordinated by a Scientific Direction including: (i) a Clinical Research Unit, managing methodologically and operationally the studies, including the formal requirements (by local institutional review boards), the interaction with the investigators, and monitoring of the quality of the data; (ii) an Informatics Unit: managing data collection and database maintenance.

Platforms for clinical research include first multiple databases implemented in each main field of interest to systematically record the routine activity, with branches related to specific research protocols. Secondly, the available technology is used for implementing validated core labs for central reading of intra-vessel imaging and cardiovascular function records in blinded fashion for multi-centre trials. Finally, structured web networking allows fluid internal and external connections for meetings, webinars, scientific journals access, etc.

The current fields of interest in the GVM group are the following:

  • intraluminal imaging and interventional procedure technology

  • pathophysiology of the vascular wall (proteomics, biomarkers)

  • transcatheter structural heart disease repair

  • advanced cardiovascular surgery

  • cardiac electrophysiology (applied in both ablation and repair procedures)

  • regenerative medicine

Geographic network

GVM is a multisite healthcare delivery organization controlling a wide and continuously growing network of hospitals spread throughout Italy and abroad. However, the level of integration and connections between the nodes of a dynamically changing network requires periodic systematic adjustments. To improve values, eliminate fragmentation and duplication of care, and optimize organization, we have introduced the ‘hub-and-spokes' model. In this model, we define the role of each hospital, concentrating work volumes within a few hospitals, choosing the best location for each clinical approach and integrating patient care across hospitals.

The hospitals have been assigned to four different geographic areas, in relation to their location. In addition, a hub for each area has been identified, intended to act as a natural ‘centre-of-gravity’ for the network of hospitals situated within the relative geographic area. The spokes, i.e. the network of hospitals comprised within the hub's gravitational system, are directly linked to their main hub, and indirectly connected, through ‘hub-to-hub’ connections, to spokes in other areas. As far as the area working plans are concerned, it should be noted that the Italian healthcare system is strongly ‘regionalized’, both in terms of clinical and administrative organization.

Finally, several actions have been conceived and implemented to improve GVM's visibility within Italy and abroad, through a marketing and communication campaign, as well as new and innovative networking instruments, such as the GVM Point initiative. The GVM Point initiative was designed to establish a network of inpatient clinics. These clinics typically provide first-level diagnostic services. The underlying franchising-like proposal was to integrate these clinical investigations with 2nd-level, 2nd-opinion ‘heavy-machine’-based options (such us MRI-scan, CT-scan, X-ray, etc.) at GVM clinics, as well as pre-surgical consultations and planning. Local affiliates can benefit from the expertise and reputation of GVM hospitals for referral of complex cases, so improving their own status. This enables even relatively small inpatient clinics to provide patients with an almost complete range of medical services and solutions.

Building an enabling information technology

The core of the GVM value agenda is to support a solid IT platform. A multidisciplinary and multidimensional organization like GVM needs to be complemented by an efficient delivery system. The IT program is focused on a platform that follows patients across services, using a common data definition and containing all patient data. Healthcare IT is acknowledged as instrumental in reducing medical errors, enhancing staff productivity, improving quality, and lowering costs. The medical path is accessible to all stakeholders and by any GVM structures, facilitating patients' referral, diagnosis and treatment, and outcome and costs measurement. The global data of GVM network will be used to implement the continuous process of quality assessment and improvement, risk management and to establish a better communication with patients.5

Conclusion

Hospitals and healthcare organizations are today operating in an extremely competitive environment, with increasing pressure to improve quality and reduce costs. In responding to this dynamic situation, transformation of organization requires the will to organize delivery around the needs of patients.

We have described the GVM organizational experience in reengineering the process by which care is delivered in order to make it more patient-focused. The GVM value agenda has been formulated based on mutually reinforcing components. The corporate organization has been redefined including a proper measurement of performance (outcomes and costs). An IT platform has been implemented, enhancing patient-centred vision, facilitating access to medical records for all parties involved in care, quality of care and costs. Despite the fact that the GVM is a complex and multisite healthcare organization, the strategic transformation has been carried out engaging all physicians in the total hospital network. The results at 18 months are very surprising: assessment of outcomes and costs in the cardiovascular field has shown an improvement in all GVM hospitals.44–47

Funding

Conflict of interest: none declared.

References

1
Cady
SH
Wheeler
JV
DeWolf
J
Brodke
M
Mission, vision and values: what do they say
Organ Dev J
 , 
2011
, vol. 
29
 (pg. 
63
-
79
)
2
David
FR
David
FR
It's time to redraft your mission statement
J Bus Strat
 , 
2003
, vol. 
24
 (pg. 
11
-
14
)
3
Jones
MB
Multiple sources of mission drift
Nonprof Volunt Sec Q
 , 
2007
, vol. 
36
 pg. 
229
 
4
Bartkus
BR
Glassman
M
Do firms practice what they preach? The relationship between mission statements and stakeholder management
J Bus Ethics
 , 
2008
, vol. 
83
 (pg. 
207
-
2017
)
5
Al Zaibag
M
Franke
JG
King Abdulaziz cardiac informatics program: an overview
Eur Heart J
 , 
2014
, vol. 
16
 
Suppl. B
(pg. 
B3
-
B6
)
6
Grayson
M
Whose mission is it anyway?
Hosp Health Netw
 , 
2001
, vol. 
85
 pg. 
6
 
7
Kets de Vries
MFR
The leadership mystique
Acad Manag Exec
 , 
1994
, vol. 
8
 (pg. 
73
-
83
)
8
Reeves
TC
Duncan
WJ
Ginter
PM
Leading change by managing paradoxes
J Leadership Stud
 , 
2000
, vol. 
7
 (pg. 
13
-
30
)
9
Orlikoff
JE
Building better Board in the New Era of Accountability
Front Health Serv Manag
 , 
2005
, vol. 
21
 (pg. 
3
-
12
)
10
Pusser
B
Slaughter
S
Thomas
SL
Playing the Board Game: An Empirical Analysis of University Trustee and Corporate Board Interlocks
J Higher Educ
 , 
2006
, vol. 
77
 (pg. 
747
-
775
)
11
Kouzes
JM
Posner
BZ
Envisioning your future: imagining ideal scenarios
Futurist
 , 
1996
, vol. 
30
 (pg. 
14
-
19
)
12
Kirkpatrik
SA
Wofford
JC
Baum
JR
Measuring motive imagery contained in the vision statement
Leadership Quar
 , 
2002
, vol. 
13
 (pg. 
139
-
151
)
13
Ancona
D
Malone
TW
Orlikowski
WJ
Senge
PM
In praise of the incomplete leader
Harvard Bus Rev
 , 
2007
, vol. 
85
 pg. 
97
 
14
Jarnagin
C
Slocum
J
Jr
Creating corporate cultures through mythopoetic leadership
Org Dyn
 , 
2007
, vol. 
36
 (pg. 
288
-
295
)
15
Suh
T
Houston
MB
Barney
SM
Kwon
I-WG
The impact of mission fulfillment on the internal audience: psychological job outcomes in a service setting
J Serv Res
 , 
2001
, vol. 
14
 (pg. 
76
-
87
)
16
Brown
TT
Noble purpose
Executive Excellence
 , 
2004
, vol. 
21
 pg. 
7
 
17
McDonald
RE
An investigation of innovation in nonprofit organizations: the role of organizational mission
Nonprof Volunt Sec Q
 , 
2007
, vol. 
36
 (pg. 
256
-
258
)
18
Van Wart
M
The first step in the reinvention process: assessment
Public Admin Rev
 , 
1995
, vol. 
55
 (pg. 
429
-
438
)
19
Sosik
JJ
Dinger
SL
Relationships between leadership style and vision content: the moderating role of need for social approval, self-monitoring role of need for social approval, self-monitoring, and need for social power
Leadership Quart
 , 
2007
, vol. 
18
 (pg. 
134
-
153
)
20
Anonymous, clear vision, dialogue help align employee actions to business goals
PR News
 , 
2011
, vol. 
67
 pg. 
2
 
21
Tellis
GJ
Golder
PN
Will and Vision: How Latecomers Grow to Dominate Markets
 , 
2002
New York
McGraw-Hill
22
DeSimone
LD
How can big companies keep the entrepreneurial spirit alive?
Harward Bus Rev
 , 
1995
, vol. 
73
 (pg. 
183
-
186
)
23
Morrison
I
Creating a vision from our values
Mod Healthc
 , 
200
, vol. 
29
 pg. 
30
 
24
Form some criticisms of these tools see Colin Coulson-Thomas. Strategic Vision or Strategic Con: rhetoric or reality
Long Range Plann
 , 
1992
, vol. 
25
 (pg. 
81
-
89
)
25
Parker
LD
Financial management Strategy in a Community Welfare Organization: a Boardroom perspective
Finan Account Manag
 , 
2003
, vol. 
19
 (pg. 
341
-
374
)
26
Nelson
WA
Bardent
PB
Organizational values statements
Healthc Exec
 , 
2001
, vol. 
26
 (pg. 
56
-
59
)
27
Wath
I
Corporate boards: now and then
Harvard Bus Rev
 , 
2011
, vol. 
89
 (pg. 
38
-
39
)
28
Hillestad
SG
Berkowitz
EN
Health Care Marketing Strategy: from Planning to Action
 , 
2004
Boston
Jones & Bartlett Publishers
29
Mission statement is key to a good marketing plan: goals should be tied to statement
Hospice Manag Advisor
 , 
2003
, vol. 
8
 pg. 
17
 
30
Freisen
ME
Johnson
JA
The Success Paradigm: Creating Organizational Effectiveness through Quality and Strategy
 , 
1995
Westport, CT
Quorum Books
31
Kaplan
RS
Norton
DP
How strategy maps frame an organization's objectives
Financial Exec
 , 
2004
, vol. 
20
 (pg. 
40
-
46
)
32
Kaval
VR
Voyten
LJ
Executive decision making
Healthc Exec
 , 
2006
, vol. 
21
 (pg. 
16
-
21
)
33
Ika
LA
Diallo
A
Thuillier
D
Critical success factors for World Bank projects. An empirical investigation
Int J Project Manag
 , 
2012
, vol. 
30
 (pg. 
105
-
118
)
34
Manville
G
Greatbanks
R
Krishnasamy
R
Parker
DW
Critical success factors for lean six sigma programmes: a view from middle management
2012
, vol. 
29
 (pg. 
7
-
14
)
35
Karlewski
J
Profit versus public welfare goals in investor – owned and not – for – profit hospitals
Hosp Health Serv Admin
 , 
1988
, vol. 
33
 (pg. 
312
-
329
)
36
Tarantino
DP
Using simple rules to achieve strategic objectives
Physician Executive
 , 
2003
, vol. 
29
 (pg. 
56
-
57
)
37
Cesaroni
F
DiMin
A
Piccaluga
A
New strategic goals and organizational solutions in large R&D labs: lessons from Centro Ricerche Fiat and Telecom Italia Lab
R&D Manag
 , 
2004
, vol. 
34
 (pg. 
45
-
57
The discussion of American Dental Partners goals is adapted from information on the ADP website
38
Chait
RP
Ryan
WP
Taylor
BE
Governance as Leadership: Reframing the Word of Nonprofrit Boards
 , 
2005
Hoboken, NJ
John Wiley & Sons
39
Charan
R
Boards that Deliver: Advancing Corporate Governance from Compliance to Competitive Advantage
 , 
2005
San Francisco, CA
JosseyBass
40
Orlikoff
JE
Old board/new board: governance in an era of accountability
Front Health Serv Manag
 , 
2006
, vol. 
51
 (pg. 
337
-
391
)
41
Maher
PM
Munro
MC
Stromer
FL
Building a better board: six keys to enhancing corporate director performance
Strategy Leadership
 , 
2000
, vol. 
28
 (pg. 
31
-
32
)
42
McLean
RA
Outside directors: stakeholder representation in investor – owned health care organizations
Hosp Health Serv Admin
 , 
1989
, vol. 
34
 (pg. 
25
-
38
)
43
Oliva
J
A seat at the power table: the physician's role on the Hospital Board
Physician Executive
 , 
2006
, vol. 
32
 (pg. 
62
-
66
)
44
Finkelstein
S
Mooney
AC
Not the usual suspects: how to use board process to make board better
Acad Manag Exec
 , 
2003
, vol. 
17
 (pg. 
101
-
113
)
45
Cascio
WF
Board governance: A. Social systems perspective
Acad Manag Exec
 , 
2004
, vol. 
18
 (pg. 
97
-
100
)
46
Daily
CM
Dalton
DR
Rajagoplan
N
Governance through ownership: centuries of practice, decades of research
Acad Manag J
 , 
2003
, vol. 
46
 (pg. 
151
-
158
)
47
Mission statement is key to a good marketing plan
Hospice Manag Advisor
 , 
2003
(pg. 
18
-
19
)