In the last few days, the news talked a lot about vaccination capacity and efficiency in Italy. Many have claimed that the vaccination rate has not been sufficient and that the Italian health department did not appropriately manage the medical campaign. This context gave the chance to talk about performance management systems adoption in the healthcare sector. What are “PMS”? What are the advantages of adopting them? Let’s dive into it.

The benefits of a proper performance management system (PMS) are:

  1. A multidimensional approach: equality, quality, sustainability, or whichever measurement of success are chosen can be all kept at high standards at the same time. The number of indicators is essential: if you have few, you may lose focus, and there may be less focus (diluting effect), so you can aggregate them to create cluster indicators, even if the process may not result easy.
  2. A clear benchmarking: comparing with other helps highlight areas of improvement
  3. Openness and accessibility: the sense of accountability increases towards the objective set when Anyone cannot hide individuals misconduct, even if its publicity should be treated carefully to avoid public scandals.
  4. Timeliness: performance should be constantly and regularly tracked so that that past data can drive tomorrow’s efforts.
  5. Clear assessment: it should take a few seconds to understand whether you are succeeding or not.
  6. Voluntariness: when the PMS is not imposed from the top but shared and maybe also co-created with the staff, commitment tends to be higher.

To design a new PMS, some of the principles from the 4DX methodology would be very helpful. “Seventy percent of strategic failures are due to poor execution of leadership. It’s rarely for lack of smarts or vision,” – Stephen Covey. When does this gap come from? This question drove Covey during all his research, in which he studied organisational and teams’ dynamic for seven years in several companies. The takeaway of his study was that the main issue was not the lack of talent, commitment, or passion; it was about the whirlwind: the whirlwind is composed of all the urgent tasks that you need to do daily to make your company survive, that rarely correspond to the significant ones. What should a wise leader do in this case? Differentiate between whirlwind and strategic tasks because they both are necessary for the organisation but very different from each other, and they constantly compete for your resources, your time one against the other, your energy and your attention. More in detail, the four disciplines are the following:

  1. Focus on the widely important goals (WIG)”: the more goals you focus on, the less you will be able to reach; here’s the reason why you have to concentrate on a few of your WIG (Wildly Important Goals). The discipline also tells how a good WIG should look to be clear, numeric and time-limited.
  2. Act on Lead Measures”: Another counterintuitive fact is that, even if a measure defines your goal, it is often impossible to act upon it directly, or some measures are way more impactful than others. According to the theory, two types of measures are individuated: Firstly, LAG measures define your goal. They are not influenceable and being historical measures; they are mainly useful for reporting the current situation. LAG measures are ultimately the most important things to be achieved, but they are not directly actionable. Then, LEAD Measures: LEAD measures define the activities that can impact your LAG measures. They are influenceable, predictive and highly repetitive. The fundamental principle behind LEAD measures is simply this: leverage on them.
  3. Keep a compelling scoreboard”: You can be super capable with the theory of lag and lead measure but using them constantly implies always knowing if you are winning to losing. Our scoreboard should be simple, visible, showing lag and leads and read in 5 seconds.
  4. Create a cadence of accountability”: The fourth discipline is to create a cadence of accountability, which is a frequently recurring cycle of accounting for past actions and results and planning new ones to move forward. Discipline 4 is where execution happens: disciplines 1, 2, and 3 set up the game, but it is when you apply Discipline 4 that execution happens.

Thus, how would it be the result once pieces are put together? First of all, Managers should select 2-3 main widely important goal, and they should reflect the main focus. What is more important for the unit? What is the narrowed focus that would impact the most? An important notice here: we are not suggesting to forget everything but three activities of the healthcare unit. There still will be a whirlwind that will account for whatever’s not selected as the primary battle (similarly to the “don’t let the guard down” principle seen during lectures). Every WIG, if necessary, can be decomposed in sub WIG so that the detailedness is not lost: the WIG should be a weighted average of different indicators that can always tell me what’s the specific issue of a non-performing WIG. In this way, both multidimensionality and simplicity are kept with a compromise.


Additionally, it would be adequate to keep the crosslight colours, ranging from 0% (red) to 100%, as it is already in the Tuscan “bersagilio” model. After selecting the WIGs and the sub WIGs, let’s use the lead and lag principle: while the sub WIG should be a LAG measure, giving us a fast glimpse of the success/failure of a narrowed area, it’s also essential to plan lead efforts for the specific sub WIG, so a series of indicators of actionable deliverables that the professionals should put in place to achieve the particular WIG. Ultimately, after setting up the whole framework, it is essential to schedule a periodical touchpoint (4DX meetings) in which the current state is reviewed, underline the specific needs and agree on commitments that should be achieved in the future. Here’s the periodicity of the meetings is crucial: the more frequently they happen, the more progress can be made.

Ok, cool literature. But how can you put theory into practice? Here’s how, in my humble opinion, an healthcare unit could exploit the 4 disciplines:

All in all, it is possible to conclude that proper management systems can save lives too.

Cited in this article:

1 Judith H. hibbard, Jean Stockard and Martin Tusler (2003). Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts? Health Affairs – Volume 22, Number 2.

2 Mannion et al (2005). Impact of Star Performance Ratings in English Acute Hospital Trusts. Journal of Health Services Research & Policy 10(1):18-24 · February 2005.

3 Chris Mcchesney, Sean Covey, and Jim Huling (2012). The 4 Disciplines of Execution: Achieving Your Wildly Important Goal. 

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