Table 1 Summary of policy change in Portuguese hospitals

Decentralization of competencies

• Purchaser/provider split: public organizations turned into public corporations and afterwards into public enterprises

• Flexible models of human resources management (individual labour contracts; appraisal system; culture of meritocracy)

• Accounts controlled by a single supervisor (board of directors) appointed by the Ministry of Health

• Directors of departments appointed among the most qualified doctors by the hospital’s board of directors

Financing control

• Performance-based funding (DRGs)

• Non-compliance with contracted activity penalizes the following year’s budget

• Budget control tools at the organizational and ward levels

• Evaluation in accordance with quantitative criteria

Managerial control

• Evidence-based procedures (cost/benefit ratio)

• Clinical guidelines (for monitoring and assessing incentives and sanctions)

• Administrative approval of medical decisions

• Opening of management positions in departments (middle-level structures of control)

• Hiring of general managers

Deregulation of the labour market

• Rise in individual contracts, short-term contracts, and service provision

• Freezing of professional careers

• Increase in wage variation within health professions

Quality and safety controls

• Monitoring technological tools

• Quality reports

• Internal and external audits and benchmarking

• Procedures to monitor malpractice