Performance evaluation in healthcare: a narrative review of recent advances and challenges in Italy

Introduction

Performance evaluation in healthcare is fundamental to improving service quality, operational efficiency, and population health outcomes (1). In recent decades, increasing attention has been paid to models that integrate clinical effectiveness with financial sustainability, particularly in systems where resource constraints are prevalent (2). In Italy, policy reforms such as Legislative Decree 150/2009 and institutional tools like the Interregional Performance Evaluation System (IRPES) have aimed to shift from a bureaucratic model of “performance administration” toward integrated performance governance. IRPES, currently adopted by 12 regions, employs approximately 400 indicators across multiple dimensions, including resilience and responsiveness during the coronavirus disease 2019 (COVID-19) pandemic (3). This shift reflects a growing emphasis on aligning performance with public value creation, stakeholder engagement, and long-term outcomes.

Despite these developments, substantial gaps remain. Local Health Authorities (ASLs) in Italy often retain an administrative approach that is not yet fully aligned with governance-oriented performance models. The literature reveals challenges such as inconsistent adoption of performance plans, limited use of outcome-based indicators, and underdevelopment of participatory evaluation tools like 360-degree feedback and competency-based assessments. In addition, cultural and organizational resistance to accountability mechanisms, and the limited presence of professional managers with hybrid clinical-managerial expertise, further hinder progress. On a broader level, several European countries have implemented more advanced and consistent performance evaluation systems. For instance, the UK’s National Health Service (NHS) Outcomes Framework (4) and Germany’s structured Qualitätsberichte (5) provide structured, transparent performance governance mechanisms that contrast with Italy’s fragmented implementation. Yet, the literature lacks a detailed comparison of these systems, leaving open questions about how such models could inform improvements in the Italian context. This narrative review aims to explore recent scientific and policy developments in healthcare performance evaluation in Italy between 2014 and 2024, with a particular focus on governance-oriented approaches. The review also compares these developments with selected European systems to identify key differences, shared challenges, and transferable practices. Finally, the review highlights implementation barriers and suggests strategies for enhancing performance governance, especially in relation to healthcare personnel evaluation, organizational accountability, and system resilience. We present this article in accordance with the Narrative Review reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-11/rc).

Methods

This narrative review stems from the research conducted as part of a Master’s thesis in Management Control (Controllo di Gestione ITA, ndr) by one of the authors. Initially compiled during the development of this thesis, the review was subsequently expanded and refined to form the basis of this article. A systematic search of major academic databases—including PubMed, Scopus, and Google Scholar—was carried out to identify scientific publications from the past 10 years, with a particular focus on the most recent 5 years (see table research strategy, 2014–2024). The analysis centered on articles examining performance evaluation of medical and healthcare personnel in Italy and Europe. The inclusion criteria were as follows: publications written in English or Italian, empirical studies and systematic reviews addressing performance evaluation models, and articles specifically focusing on the healthcare sector with a particular emphasis on the Italian and European contexts. Articles unrelated to the topic, those published outside the selected timeframe, and studies conducted exclusively in non-healthcare settings were excluded. The search summary strategy can be found in Table 1.

Results

The data were analyzed qualitatively, with a focus on performance governance models, the indicators used, and their implications for organisational improvement. During the review process, over 100 articles published in the past 5 years were examined, of which 30 met the inclusion criteria and were selected (Table 3). These articles were identified and evaluated as relevant studies on healthcare performance evaluation in Italy and Europe, and the selection was summarised in a table detailing the authors, titles, journals or books, and the focus of each study.

Of the 30 articles selected, 21 focused primarily on the Italian healthcare context, while 9 offered comparative insights from European countries such as the United Kingdom, Germany, France, and Spain. Thematically, the articles were grouped into two broad categories: (I) administrative performance models (n=13), emphasizing compliance, efficiency metrics, and reporting requirements; and (II) governance-oriented models (n=17), which emphasized participatory evaluation, public value creation, and strategic alignment with health policy objectives.

Within the Italian literature, a majority of studies (15 out of 21) described persistent reliance on administrative approaches, such as linear performance plans and input-based assessment tools. Only a smaller subset (6 articles) explicitly addressed integrated performance governance, highlighting innovations like competency-based evaluations, use of balanced scorecards, and managerial accountability frameworks. Comparative articles illustrated more advanced integration of outcome-based indicators, particularly in the NHS Outcomes Framework (UK) and Germany’s Qualitätsberichte. These findings underscore a trend toward governance models in some contexts, while revealing a dominant persistence of administrative evaluation in many Italian ASLs.

Discussion

General trends in healthcare performance evaluation

The evaluation and management of performance in healthcare has been the subject of numerous recent studies, with a particular emphasis on the “need for advanced governance models that foster collaboration, dialogue, and the achievement of strategic objectives” (6). As Fanelli et al. (1,7-9) argue, strengthening the role of “professional managers” is essential for ensuring effective communication, setting realistic objectives, and evaluating quality and efficiency. Despite progress in regulations and methodologies, the literature often falls short in addressing the adoption of governance models aimed at generating public value. Despite progress in regulations and methodologies, the literature often falls short in addressing the adoption of governance models aimed at generating public value (10). In Italy, the IRPES is a notable example of progress, encompassing 12 regions and monitoring approximately 400 indicators, including resilience factors that were particularly evident during the COVID-19 pandemic (3). Specific evaluation mechanisms introduced by the Ministry of Health, such as annual assessments of public veterinary health services, have improved resource planning and allocation (6). Nonetheless, a study involving 13 healthcare organisations in Emilia-Romagna highlighted gaps in the governance tools reflected in strategic documents, “stressing the need to better integrate the concept of public value into healthcare practices” (10,11).

From administrative models to performance governance

Research by Costumato et al. (12) focused on the performance plans of Italian ASLs from 2020 to 2022, finding that many remain at the early stages of the performance management cycle. These organisations predominantly rely on administrative approaches (performance administration) rather than adopting integrated models of performance governance. These findings align with the theoretical framework proposed by Bouckaert and Halligan, which emphasizes the need for advanced management tools in light of reforms introduced by Legislative Decree 150/2009 (13). Performance evaluation in Italian public administration has undergone significant transformation in recent years, playing an increasingly central role in governance and oversight processes. The introduction of the “Performance Plan” in 2009, as mandated by the Brunetta Reform, marked a significant shift from input-based management (focused on allocated resources) to a results-oriented approach (6,14). This reform aimed to improve the efficiency of public administration and enhance its tangible impact on communities, promoting transparency and accountability through the monitoring and evaluation of both processes and outcomes (10). However, the distinction between “performance administration” and true “performance governance” is often misunderstood or inadequately applied in practice.

The former is characterized by formal compliance and bureaucratic reporting, whereas the latter requires strategic alignment, participatory leadership, and dynamic performance monitoring capable of driving value creation and institutional resilience (12,14,15).

Evolution of public sector evaluation approaches

In the broader public sector, performance evaluation has undergone a profound transformation, shifting from an input-driven focus to a results-oriented model. According to Nisio et al. (14), the “Performance Plan” introduced under the Brunetta Reform has been a cornerstone for promoting accountability and transparency. This shift has extended into academia, where “performance measurement now incorporates elements such as scientific productivity, innovation, and social impact”, as noted by Aversano et al. (2,16). Despite these advancements, significant challenges remain, including the integration of outcome indicators and the assessment of long-term effects on communities served (17). At the organisational level, the evolution of performance management has redefined the role of senior management. Today, managers are expected to act as “public entrepreneurs”, steering organisations toward strategic objectives. Mussari and Ruggiero (15) emphasize the importance of “strengthening managerial skills and adopting integrated evaluation methodologies to improve organisational effectiveness”. Tools such as evaluation scorecards and observation grids have proven essential for standardizing processes, enhancing transparency, and ensuring replicability. However, performance evaluation remains a dynamic process that is fundamentally aimed at measuring results while fostering continuous improvement and sustainability (14).

Indicators, tools, and organisational innovation

In the healthcare sector, performance governance is closely tied to the adoption of indicators that measure not only immediate outputs but also long-term outcomes. While regulations and guidelines have provided a more structured framework for evaluation, they have not always been tailored to the specific needs of regional healthcare organisations, which presents an opportunity for refinement and adaptation. Cardarelli et al. (18) point out that “regional disparities create significant barriers to harmonising practices and stress the importance of developing adaptable models that account for contextual factors”. This concern is echoed across several European systems, where centralised national frameworks, such as the UK’s NHS Outcomes Framework and Germany’s Qualitätsberichte (4,5) have demonstrated stronger integration of outcome indicators, public reporting obligations, and links to funding mechanisms. These elements remain inconsistently applied in the Italian setting, contributing to the persistence of territorial inequities.

Over time, performance measurement tools have evolved to include both quantitative metrics, such as productivity and cost-effectiveness, and qualitative dimensions, such as staff well-being and user satisfaction (19). The emergence of “professional managers”, who combine clinical and managerial expertise, has played a critical role in fostering collaboration and driving ongoing improvement. Fanelli et al. underscore “the importance of these roles in addressing challenges related to innovation and modernization within the healthcare system” (3-7). Despite these innovations, the literature continues to highlight that cultural resistance, lack of managerial accountability, and limited digital infrastructure still hinder full implementation of modern performance systems in Italy. These barriers are often underexplored yet remain critical for understanding the slow adoption of advanced governance tools, especially at the local organisational level. Additionally, research by Aversano et al. (2) highlights the positive impact of gender diversity in leadership, showing that greater representation of women in leadership roles is associated with improved financial and operational performance, thus reinforcing the value of inclusive policies. Performance evaluation systems depend on the adoption of advanced tools and a cultural shift toward meritocracy, transparency, and staff engagement. These systems are most effective when they align individual performance with broader organisational goals, as outlined in the “Manuale Operativo per la Performance” (15). This alignment is achieved through dual dimensions: results, which focus on achieving objectives as measured by specific indicators, and organisational behaviours, which assess key skills and attitudes such as leadership, teamwork, and problem-solving. “Practical tools, such as scorecards and observation grids, have been developed to standardize the evaluation process across organisational levels”. For instance, scorecards enable comparative analysis of employee performance, while observation grids facilitate the monitoring of key behaviours. These tools not only enhance evaluation systems but also ensure transparency and replicability. Dal Mas et al. (20) argue that “incorporating principles like sustainability and public value into these frameworks is essential for advancing healthcare governance”. Continuous training, coaching, and participatory models have emerged as critical drivers of organisational transformation and performance improvement. In Italian ASLs, performance evaluation is carried out through several phases, including planning, data collection, and final evaluation, which have gradually evolved into more strategic and integrated methodologies. Recent research underscores the importance of performance management practices rooted in advanced methodologies, transparent criteria, and innovative tools (12). “Performance evaluation in healthcare organizations relies on tools and techniques designed to ensure consistency, objectivity, and a focus on identifying areas for improvement” (6). Both validated tools and innovative methods play a critical role in assessing skills, gathering multidimensional feedback, and implementing targeted training interventions (3). For instance, the Objective Structured Clinical Assessment (OSCA) has proven particularly effective in university-level training by evaluating specific clinical competencies through simulations and practical scenarios (6). This approach is instrumental in identifying learning gaps and creating customized educational programs to address them. Additionally, the 360-degree evaluation, as emphasized by Cioffi et al. (21), “provides significant value in assessing cross-cutting skills such as communication, emotional intelligence, and conflict resolution”. The integration of coaching programs informed by these evaluations has led to notable improvements in key competencies among healthcare professionals, highlighting the importance of combining traditional and innovative practices tailored to diverse healthcare settings.

These methodologies showcase how combining traditional and modern evaluation techniques can strengthen performance management in healthcare, driving continuous professional development and better organisational outcomes. In addition to these methodological innovations, the COVID-19 pandemic has further exposed vulnerabilities in performance governance structures, revealing limitations in real-time data integration, cross-sector coordination, and staff safety metrics (22). These insights should inform future policy reforms aimed at embedding resilience as a core evaluation dimension across all levels of the healthcare system (23).

In the healthcare sector, competency-based evaluation is especially significant in emergency care, where clinical expertise and decision-making skills are critical (6). It has been reported (6) how Piani et al. (24) developed a robust model for assessing nursing competencies, identifying 12 essential domains, including stress management, rapid response proficiency, and precision in clinical procedures.

Another notable advancement is the integration of competency management models throughout the educational continuum, bridging university education with professional practice. As Sureda-Demeulemeester et al. (25) emphasise, adopting standardised tools and innovative techniques enhances professional training and elevates the quality of patient care. Similarly, Pierri (26) advocates for a revised training framework based on non-formal learning and competency certification, which blends practical experiences with theoretical instruction to offer a more flexible and adaptive approach to addressing the educational needs of the healthcare sector.

A key aspect of competency development is evaluating return on investment (ROI) in training programs (27). Performance evaluation and professional development are interdependent tools that drive improvements in the quality and efficiency of healthcare services. Continuous education, supported by innovative methodologies like coaching and competency certification, is a strategic tool for addressing the dynamic challenges of the evolving healthcare landscape. As many scholars suggest, evaluation and training should not be seen as isolated goals but as instruments for facilitating cultural and organisational transformation (6,27). Investing in staff development enhances service quality while fostering a more inclusive, motivating, and supportive work environment.

Contractual dimensions and incentive structures

Other crucial aspect is the contractual agreement, pivotal for integrating organisational objectives with employee roles and expectations. Through integrative bargaining, these agreements seek to align the strategies of healthcare organisations with staff contributions, ensuring a fair and transparent distribution of responsibilities and incentives. One of their primary aims is to establish a clear regulatory framework that governs critical areas such as career advancement, the allocation of economic incentives, and resource distribution. Contractual agreements help create a cohesive and high-performing healthcare workforce by connecting individual goals with organisational priorities. The diversity of roles and competencies in the healthcare sector necessitates precise management to maintain fairness and consistency. The Italian “Contratto Collettivo Nazionale di Lavoro (CCNL)” for healthcare is a critical regulatory framework detailing performance-based incentives and objective negotiation procedures. Academic literature identifies several essential aspects of collective bargaining in this context. Dalla Sega explored integrative healthcare policies within collective agreements, observing a trend toward centralising resources in significant sectoral funds (28). While this centralisation enhances economic sustainability, it also raises concerns, such as limiting the decision-making autonomy of individual healthcare organisations. In contrast, other authors (29) advocate for decentralising bargaining structures, emphasising that innovative practices often emerge at the organisational level, where agreements can be tailored to meet the specific needs of local contexts and institutions. Beyond managing economic resources, contractual agreements are pivotal in improving work quality and recognising staff competencies. Alaimo (30) illustrated how integrative bargaining in universities has established transparent criteria for economic and professional progression, ensuring more equitable resource distribution across various professional categories. In the healthcare sector, performance-based economic incentives foster continuous improvement and motivate staff to achieve strategic goals. However, challenges arise when clear and measurable performance indicators are often still absent, or the organisational culture does not adequately support performance-based systems.

Integrative bargaining is also a catalyst for driving the cultural transformation required to modernise the public sector. Constructive dialogue among stakeholders enables more participatory, results-oriented management practices, creating the foundation for an efficient, equitable, and sustainable healthcare system. Article 8 of Legislative Decree 150/2009 highlights the necessity of clear, measurable indicators for continuous performance monitoring, providing a methodological basis for these efforts.

By combining centralised and decentralised approaches and integrating economic and cultural considerations, contractual agreements can support the healthcare sector’s transition toward a more dynamic and adaptive model better suited to address modern challenges while ensuring equitable treatment and resource allocation.

Limitations

Lastly, this review has several limitations. Being a narrative review, it does not provide a quantitative synthesis of IRPES or other model outcomes. Moreover, the analysis was limited to studies published in English and Italian, potentially omitting relevant experiences from other European contexts. The thematic focus on governance and evaluation tools, while relevant, may also limit generalizability to other health system dimensions, such as clinical performance or patient-reported outcomes.

Conclusions

Performance management in healthcare is a strategic lever for achieving sustainable, equitable, and high-quality service delivery. In Italy, there is a growing shift from compliance-based models toward more integrated forms of performance governance, but persistent gaps remain—particularly in aligning evaluation frameworks with long-term outcomes and public value creation. Innovative tools such as balanced scorecards, 360-degree feedback, and competency-based assessments show promise, but cultural resistance and lack of standardization still hinder full implementation.

To accelerate this transition, policymakers should promote standardized, outcome-based evaluation frameworks linked to funding mechanisms and organizational accountability. Healthcare organizations must invest in training hybrid clinician-managers capable of leading participatory performance models. Future research should assess the long-term impact of integrated governance systems on health equity, resilience, and workforce motivation, using comparative and longitudinal methods. Performance evaluation should ultimately go beyond measuring activities—it must track how systems evolve to create sustainable public value.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-11/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-11/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-11/coif). O.V. is a current employee of H.R. Consultancy Cypher. N.P., G.D.V., and C.C. are current employees of C.M.R. SpA. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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