<p>Financial incentives have become important in health care all over the world. This thesis compares one council implementing a new payment system based on performance based reimbursement (PBR) with ten councils retaining an annual budget system. </p><p>The aim of this thesis was to study the effects of PBR on physicians’ attitudes and behaviours, that may affect the conditions for cost effective care. Aspects highlighted are efficiency, cost awareness, quality of care, professional autonomy and power, job satisfaction and leadership.</p><p>This thesis is based on data from seven studies, questionnaires, interviews and register based studies. One instrument, Incentive, Effectiveness, Environment (IEE) was developed within the framework of this thesis. It measures self-reported behavioural changes related to daily clinical work, judgements about work environment factors and the quality of care, and attitudes towards and existence of financial incentives.</p><p>Physicians in the council with PBR experienced a greater pressure to improve their efficiency and they did so. The average length of stay decreased more both in relative and absolute numbers. Much of the efficiency increase, however, seems to emanate from "running faster", not from working more rationally. Cost awareness increased in all councils studied although more so in the council with PBR. PBR was found to create a different financial incentive than an annual budget, stronger and more positive. Effects on quality of care were judged to be negative. Financial reductions were claimed to be the main reason for quality losses, but PBR was found to be more time consuming and therefore contributed to the negative outcome. Work environment factors, especially professional autonomy and power were judged to have deteriorated in all councils studied although more so in the council with PBR. Good leadership was shown to make a difference for quality of care as well as for professional autonomy and job satisfaction, regardless of context.</p><p>The results seem, at least partly, to depend on the new payment system, creating an increased efficiency pressure. Additional reasons discussed in this thesis are financial reductions, repeated organisational changes and a size effect.</p>

Financial incentives have become important in health care all over the world. This thesis compares one council implementing a new payment system based on performance based reimbursement (PBR) with ten councils retaining an annual budget system. The aim of this thesis was to study the effects of PBR on physicians’ attitudes and behaviours, that may affect the conditions for cost effective care. Aspects highlighted are efficiency, cost awareness, quality of care, professional autonomy and power, job satisfaction and leadership. This thesis is based on data from seven studies, questionnaires, interviews and register based studies. One instrument, Incentive, Effectiveness, Environment (IEE) was developed within the framework of this thesis. It measures self-reported behavioural changes related to daily clinical work, judgements about work environment factors and the quality of care, and attitudes towards and existence of financial incentives. Physicians in the council with PBR experienced a greater pressure to improve their efficiency and they did so. The average length of stay decreased more both in relative and absolute numbers. Much of the efficiency increase, however, seems to emanate from "running faster", not from working more rationally. Cost awareness increased in all councils studied although more so in the council with PBR. PBR was found to create a different financial incentive than an annual budget, stronger and more positive. Effects on quality of care were judged to be negative. Financial reductions were claimed to be the main reason for quality losses, but PBR was found to be more time consuming and therefore contributed to the negative outcome. Work environment factors, especially professional autonomy and power were judged to have deteriorated in all councils studied although more so in the council with PBR. Good leadership was shown to make a difference for quality of care as well as for professional autonomy and job satisfaction, regardless of context. The results seem, at least partly, to depend on the new payment system, creating an increased efficiency pressure. Additional reasons discussed in this thesis are financial reductions, repeated organisational changes and a size effect.

Dagens hårda konkurrens för tillverkande företag ställer höga krav på effektivisering, lönsamhet samt att ständigt utveckla sina processer. Att arbeta med förbättringar är en väsentlig del för företagens överlevnad. För att lyckas med förbättringsarbeten krävs en förståelse för vilken process som ej är fullkomlig. Detta kan uppnås genom att identifiera och analysera de slöserier som finns inom företaget, för att sedan eliminera dem. I detta arbete lägger vi grunden för kommande förbättringsarbeten genom att identifiera de platser och orsaker till spill, och sedan beräkna dess kostnad. En fallstudie som ska analysera en delprocess som ej skapar värde för kunden utförs för att ytterligare belysa potentiella förbättringsområden. Genom intervjuer, observationer och analys av befintlig data har en ny modell för registrering av kassationer och omarbete skapats och en intern prislista för produkter i arbete har uppdaterats. En fallstudie har utförts där två partier kött från olika leverantörer har bearbetats till slutkund. Syftet med fallstudien var att undersöka om skillnad i leverantörskvalitet kunde speglas i slutpriset av produkten. Parametrar som tid i lager, nedlagda resurser och förlorad vikt iakttogs. Inför framtida förbättringsarbeten kan modellen i kombination med prislistan användas som grund för beslut. Fallstudie påvisar de konsekvenser som kan uppstå vid ett funktionsorienterat arbetssätt. / The harsh competition the producing organizations face these days, sets high expectations concerning effectivity, profitability and process development. To improve the organization is an essential part for survival. In order to successfully improve your organization you should first identify what process that’s in dire need. This can be achieved by identifying, analyzing and eliminating the wastes inside the company. This report sets the foundation for future improvements by identifying the locations, reasons and economic consequences of waste. A case study whose purpose was to analyze an activity which didn’t add value for the customer was performed to reveal additional areas of improvement. Through interviews, observations and studies of documented data, a new model for the registration system was created. These methods were also used to create an updated version of their internal price list. A case study were performed where two batches of meat, from different suppliers, were followed through processing. The purpose were to examine whether there is a link between supplier quality and increment of cost. Parameter such as time spent in stock, resource consumption and loss of weight where observed. The model combined with the price list can be used as a basis for future decisions regarding improvements. The case study demonstrates the consequences associated with a functional oriented business approach.

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