European Heart Journal Supplements (2015) 17 (Supplement A), A3–A7

The Heart of the Matter

doi:10.1093/eurheartj/suv003

Strategic management of a healthcare organization:

engagement, behavioural indicators, and clinical
performance
Giuseppe Speziale*
Anthea Hospital, GVM Care & Research, Via C. Rosalba, 35/37, 70124 Bari, Italy

KEYWORDS
GVM Care & Research;
Healthcare organizations;
Strategic management;
Engagement;

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Behavioural indicators;
Clinical performance

Introduction GVM Care & Research is a holding operating in the health,

Healthcare organizations today are facing a series of pro-
blems due to two main factors: increasing difficulty in sat-
isfying 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 tech-
nology and approach. A continuous increase of complexity
and the capacity of physicians will not ensure the funda-
mental requirement of any business: to really deliver
what its customers need. Hence, it is time for a revolution-
ary 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 revolu-
tion 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.
* Corresponding author. Tel: +39 080 5644111, Fax: +39 080 5644678,
Email: gspeziale@gvmnet.it
pharmaceutical, spa-well-being, research, biomedical in-
dustry, 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 numer-
ous 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 cardiovascu-
lar diseases and their prevention mediated by innovative

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015.
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A4
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 clin-
ical governance rules; (ii) driving the changes by work
volume and performance, in a single matrix; (iii) increas-
ing 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).
The task of building a vision for an organization is fre-
quently referred to as ‘path-finding’. The goal of the path-
finder 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 ex-
cellence, 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 connec-
tions;
(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 im-
provement, increased number of patients referred, in-
novative techniques, inpatient clinics plan (GVM point
program), innovation and production in clinical re-
search, and presence and competitiveness in Europe.
Organizational culture
To successfully implement the strategy, a change in ‘organ-
izational culture’ is required. Although cultural change is
Figure 1 The GVM value agenda.
G. Speziale
difficult, it is often an important factor in moving the
healthcare system toward realizing its strategy. An organ-
izational 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 organiza-
tional structure in order to facilitate the implementation
of the overall strategy11–20 (Figure 2).
Clinical program, performance, and reporting
to drive improvement
The healthcare future will be based on larger and inte-
grated systems, patient-centred care, a new relationship
between hospitals and physicians, and a shift of many in-
patient 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 lan-
guage, GVM has defined guidelines for a strategic plan fo-
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cusing on high-quality, medically excellent procedures,
innovative techniques, participation in international net-
works, 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) eco-
nomic indexes, and (iv) reputation index (Figure 3).
Area performances, as well as the medical team perfor-
mances, 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 de-
scribe the Group’s positioning and capability, both horizon-
tally (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 identi-
fied 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 per-
formance. Financial incentives were used in GVM in the
past but they were not sufficient to optimize doctors’ per-
formance. Since comparing outcomes is complicated, we
Strategic management of a healthcare organization
Figure 2
Figure 3 GVM area and hospital score indexes.
have implemented coordination, information sharing and
team work as performance measures.33–43
These systematic measurements of results and the peri-
odic activity of reporting outcomes using peer pressure
have produced significant improvement in quality of
care, outcomes and costs in GVM and have positively influ-
enced several important indicators in the cardiovascular
area:
A5
Organizational structure of GVM.
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(1) the volume of cardiovascular surgical procedures per-
formed 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.
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.
Clinical research
Scientific research is a necessary component of a health-
care institution working in areas where culture, technol-
ogy, and clinical care processes move quickly and need
continuous updating, first so as to keep abreast of intellec-
tual 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 man-
agement, but rather it should be a primary component
in the array of mid- to long-term goals, and also part of
the investment plan.
A6
The structure and planning of the scientific activity of the
GVM network is coordinated by a Scientific Direction includ-
ing: (i) a Clinical Research Unit, managing methodologically
and operationally the studies, including the formal require-
ments (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 avail-
able technology is used for implementing validated core
labs for central reading of intra-vessel imaging and cardio-
vascular function records in blinded fashion for multi-
centre trials. Finally, structured web networking allows
fluid internal and external connections for meetings, webi-
nars, 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 con-
trolling a wide and continuously growing network of hospi-
tals spread throughout Italy and abroad. However, the level
of integration and connections between the nodes of a dy-
namically 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 lo-
cation for each clinical approach and integrating patient
care across hospitals.
The hospitals have been assigned to four different geo-
graphic 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’ con-
nections, 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 imple-
mented to improve GVM’s visibility within Italy and abroad,
through a marketing and communication campaign, as well
G. Speziale
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 under-
lying 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 rela-
tively 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 organ-
ization 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 sta-
keholders and by any GVM structures, facilitating patients’
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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 assess-
ment 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 compo-
nents. The corporate organization has been redefined in-
cluding 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 multi-
site healthcare organization, the strategic transformation
has been carried out engaging all physicians in the total hos-
pital 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.
Strategic management of a healthcare organization
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