An analysis of the state of the health care system of Ukraine was performed and the expediency of changing approaches to managing projects for the creation of hospital districts was substantiated. The expediency of developing a conceptual model of adaptive value management of project portfolios for creating and developing hospital districts is substantiated. There is proposed a conceptual model of adaptive value management of project portfolios for the creation and development of hospital districts involves five stages, at which ten main, five auxiliary, and four service processes are systematically performed. Interrelationships between management processes and their results are determined. They are the basis of the formulation of management tasks and the development of tools for their solution. An assessment of the existing state of the creation of hospital districts in Ukraine was carried out. Contradictions were identified in the declared Lviv hospital district. It is established that under the existing configuration of the Lviv Hospital District, part of rural communities remains medically unprotected. The obtained results of the conducted studies indicate that the reform of the health care system in Ukraine is being carried out with many errors due to the approach to management. Further research should be conducted in the direction of the development of models, methods, and algorithms for the implementation of management processes specified in the conceptual model, which belong to the methodology of adaptive value management of portfolios of projects for the creation of hospital districts.
Today, the health care system of Ukraine functions inefficiently. This leads to low-quality
treatment of patients and increased mortality, compared to developed countries of the world [
Effective management of portfolios for the creation and development of hospital districts requires solving several scientific and applied management problems. This necessitates the development of a mechanism that will ensure the implementation of appropriate management processes. One such unsolved problem is the development of a conceptual model of adaptive value management of portfolios of projects for the creation of hospital districts, which is based on the methodology of portfolio management, takes into account the specific features of the project environment of individual regions and current regulations regarding the architecture and value of the operation of hospital districts. The development of the specified conceptual model will ensure adequate initiation of projects for the creation and development of hospital districts with maximum value for stakeholders and adaptation to their specific project environment. Based on the conceptual model of adaptive value management of portfolios of projects for the creation of hospital districts, the management processes of harmonizing the configuration of projects for the creation and development of hospital districts with the configuration of their project environment will be performed based on the modeling of the specified projects. The results of modeling will ensure the formation of portfolios of projects for the creation and development of hospital districts with maximum value for stakeholders in a given specific project environment.
The national strategy for reforming the healthcare system in Ukraine envisages a change in its
architecture [
In addition, it is proposed to reform the hospital network of individual regions of the state by
combining hospitals into a single hospital space. For this purpose, the resolution of the Cabinet of
Ministers of Ukraine dated November 30, 2016 No. 932 "On approval of the Procedure for the
establishment of hospital districts" was adopted [
The foreign experience of the functioning of the health care system shows that outpatient treatment, which provides prevention and the provision of emergency medical care to residents of certain territories, including rural communities that are far from intensive care hospitals, is being developed and supported in all OECD countries.
Adequate project management involves forecasting the changing project environment for each
of the projects during the creation of hospital districts in an individual region. In addition, the state
of use of the product of individual projects based on their simulation is evaluated. This leads to the
need to conduct specific research and develop a conceptual and service model of adaptive value
management of project portfolios for the creation of hospital districts in an individual region [
Considering foreign research, it is possible to note certain scientific works [
To objectively substantiate the structure of hospital districts for individual regions, a methodology and conceptual model of adaptive value management of project portfolios for their creation should be developed [21-23]. It is the specified conceptual model that reflects cause-and-effect relationships between management processes with their specificity. In particular, they are focused on creating maximum value for stakeholders by adapting the configuration of hospital districts to a particular changing design environment simulated with the use of computational intelligence [24-26]. In addition, the implementation of processes of intelligent forecasting of value indicators of projects is foreseen [27-30]. This ensures the creation of effective portfolios and, accordingly, high-quality substantiation of the configuration of hospital districts in the desired state.
The purpose of the study is to substantiate the conceptual model of adaptive value management of portfolios of hospital district creation projects which will ensure maximum value for stakeholders thanks to the adaptation of the configuration of hospital districts to a special changing project environment that ensures the creation of their effective portfolios and, accordingly, qualitative justification of the configuration of hospital districts in the desired state.
To achieve the goal, the following tasks should be solved:
1. to propose a conceptual model of adaptive value management of project portfolios for the creation and development of hospital districts;
2. assess the current state of the creation of hospital districts in Ukraine and justify the feasibility of developing a methodology of adaptive value management of project portfolios for the creation and development of hospital districts.
To carry out quality management processes of project portfolios for the creation of hospital districts, based on taking into account the state of the changing project environment, a should be developed a mechanism that provides solutions to several specific management tasks [31-35]. This necessitates the development of models, methods, and algorithms that ensure the implementation of the specified management processes. First of all, to implement adaptive value management of project portfolios for the creation of hospital districts, it is necessary to develop a conceptual model (Figure 1).
7) separate projects of reconstruction and creation of hospitals included in the portfolio of projects for the creation of hospital districts are evaluated based on calculations of their value indicators, taking into account the changing project environment;
8) models and methods have been developed to determine the indicators of the value of reconstruction projects and the creation of hospitals and the systemic value of portfolios of projects for the creation of hospital districts, taking into account their specificities;
9) methods have been developed for the management processes of coordinating the configuration of reconstruction projects and the creation of hospitals with the configuration of their project environment that take into account their peculiarities;
10) the processes of determining the effective architecture of the portfolio for the creation of hospital districts and their balancing based on the results of the evaluation of the system value for stakeholders are carried out;
11) the processes of creating a plan for the implementation of a portfolio of projects for the creation and development of hospital districts and its implementation are cyclical and are carried out based on justifying the feasibility of changes in the architecture of the portfolio of projects for the creation and development of hospital districts due to changes in the project environment.
It is the specified model that makes it possible to meaningfully reflect the structure of processes of adaptive value management of portfolios of projects for the creation of hospital districts PRPM .
A feature of the proposed model is the display of the main PRBA , auxiliary PRAU and service PRSE processes of adaptive value management of portfolios of projects for the creation of hospital districts:
PRPM PRBA PRAU PRSE , (1) where PRPM – are processes of adaptive value management of portfolios of projects for the creation of hospital districts; PRBA – are the main processes of adaptive value management of portfolios of projects for the creation of hospital districts; PRAU – are auxiliary processes of adaptive value management of portfolios of projects for the creation of hospital districts; PRSE – are service processes of adaptive value management of portfolios of projects for the creation of hospital districts.
The main processes PRBA of adaptive value management of project portfolios for the creation of hospital districts directly relate to the formation of effective project portfolios based on value assessment and making changes to them due to changes in the project environment [36-40]. As a result of the implementation PRBA , dynamic plans for the implementation of project portfolios for the creation of hospital districts with architecture that ensures maximum value and adaptability to the existing state of the project environment (types, number, and dynamics of morbidity of the population in the given territory, the available medical and material base for patient care, regulatory and legislative basis, the amount of financing of reforms in the medical field in the given territory, etc.). The processes PRBA include:
PRBA : PIC , PIP , PCP , PPR , PPA, PFP , PBP , PPI , PID , PMC , (2) where PIC – is identification of contradictions in the territorial healthcare system; PIP – is identification of problems and formulation of tasks for the creation and development of hospitals; PCP – is coordination of project configurations and their project environment; PPR – is initiation of projects for the creation and development of hospital districts; PPA – is coordination of the portfolio architecture of hospital district development projects; PFP – is formation of an effective portfolio of projects for the creation and development of hospital districts; PBP – is balancing the project portfolio for the creation and development of hospital districts; PPI – is creation of a plan for the implementation of a portfolio of projects for the creation and development of hospital districts; PID – is implementation of a project portfolio for the creation and development of hospital districts; PMC – is monitoring and control of project portfolio implementation.
Auxiliary processes PRAU of adaptive value management of project portfolios for the creation of hospital districts ensure the implementation of the main ones and only contribute to their implementation and do not take direct participation in the formation of plans for the implementation of portfolios of projects for the creation of hospital districts.
The processes PRAU include
PRAU : PAS , PSM , PAV , PSV , PAC , (3) where PAS – is an assessment of the state of the territorial healthcare system; PSM – is substantiation of models of component projects and their project environment; PAV – is evaluation of the value of separate projects of creation and development of hospital districts; PSV – is assessment of the systemic value of the portfolio of projects for the creation and development of hospital districts; PAC – is assessment of changes in the portfolio of projects for the creation and development of hospital districts.
Service processes PRSE of adaptive value management of project portfolios for the creation of hospital districts relate to the assessment of the dynamic project environment, forecasting its changes and the expediency of changes in the architecture of the portfolios of projects for the creation of hospital districts. This ensures the implementation of the main and auxiliary processes of the specified management.
The process PRSE include
PRSE : PDS , PDK , PI A , PJA , (4) where PDS – is an analysis of the development strategy of the territorial healthcare system; PDK – is the formation of a database and knowledge; PI A – is an intellectual analysis of the existing state of the territorial healthcare system; PJA – is substantiating the expediency of changes in the architecture of the project portfolio.
The main difference between the main PRBA , auxiliary PRAU and service PRSE processes of adaptive value management of project portfolios for the creation of hospital districts is that the results of the activity PRBA systematically ensure the formation of effective project portfolios and the introduction of changes in their architecture as needed [41-44]. The processes PRAU ensure the determination of the value components of both individual projects for the creation of hospital districts and the system value of their implementation in the portfolio. At the same time, the processes PRSE provide an assessment of the current state and forecasting of the changing components of the project environment, both for individual projects of creating hospital districts and systemically for their portfolios. The execution of the processes PRSE makes it possible to determine the changing trends of the changing project environment, which is the basis for adapting the configuration of hospital district creation projects to their environment and, accordingly, ensuring the creation of maximum value for their stakeholders.
The proposed conceptual model (Figure 1) provides for the systematic implementation of 5 stages. The first stage, there are carried out management processes PRI , which ensure the identification of problems and the formulation of tasks for the creation and development of hospitals, which involves the implementation of processes of all levels that are interconnected
PRI : PDS PDK PAS PIC PIP . (5)
The management of portfolios of projects for the creation and development of hospital districts begins with service processes, which include the processes of analysis of the strategy for the development of the territorial healthcare system PDS and the formation of a database and knowledge PDK .
To carry out the process of analysis of the strategy for the development of the territorial healthcare system PDS (Strategy for the development of the healthcare system of the state and its administrative regions), a meaningful description of project products and the need for their inclusion in the portfolio of creating hospital districts is carried out. At the same time, an analysis of the main values received by stakeholders is carried out. The formation of base data and knowledge PDK is carried out from statistical data of individual communities, districts and regions regarding diseases of the population and the results of their treatment. This provides knowledge about the changing design environment of the area where the hospital district is being created. Based on the processes PDS and PDK , the auxiliary process of assessing the state of the territorial healthcare system PAS according to value indicators is performed. It is the basis of the implementation of the main management processes of identifying contradictions in the territorial healthcare system PIC , as well as identifying problems and formulating tasks for the creation and development of hospitals PIP . The process PIC is carried out on the basis of system and factor analysis of the territorial healthcare system using developed models. They ensure the establishment of cause-and-effect relationships between separate groups of factors of the value of the creation and development of hospital districts and the identification of the peculiarities of their impact on the value for individual stakeholders. In addition, the results of the process PIC ensure the establishment of existing contradictions between the values of individual stakeholders, which are the basis of the formulation of existing problems and tasks for a given territory. At the second stage of managing portfolios of projects for the creation and development of hospital districts, management processes PRII which ensure coordination of project configurations and their project environment are performed
PRII :
PPR PCP PSM PAV PDK PIA , (6)
Based on the results of the process of identifying problems and formulating tasks for the creation and development of hospital districts PIP , the process of initiating projects for the creation and development of hospital districts PPR is carried out. During the execution of the process PPR , the identification features of hospital construction projects of different levels, which will ensure the creation of value for stakeholders with adaptation to their specific project environment should be substantiated. In addition, the results of service processes PDK (availability of a complete database and knowledge), PIA (characteristics of the existing state of the territorial healthcare system), as well as auxiliary processes of substantiation of the models of component projects and their design environment PSM and evaluation of the value of individual projects of creation and development of hospital districts PAV should be available to perform the process of matching project configurations and their design environment PCP . The results of the process PPR (possible scenarios for the creation of hospitals of different levels and project implementation options), as well as auxiliary processes PSM (substantiated models of component projects and their project environment) and PAV (indicators of the value of individual projects of the creation and development of hospital districts) ensure the implementation of the process of coordinating project configurations and their project environment PCP . The implementation of the specified process requires the development of a specific management mechanism, which takes into account the uniqueness of certain types of projects for the creation of hospitals of different levels which have their own specific configuration objects and are implemented in their changing project environment, which requires adaptation to it. The main hypothesis of this mechanism is that for a given administrative territory (district or oblast) which is characterized by the predicted volumes of certain types of diseases of the population of different age groups which requires medical assistance at different levels, it is always possible to implement projects for the creation of MultiCare hospitals of intensive treatment of the first and second levels that will provide the desired value for stakeholders. The configuration of the products of the projects for the creation of intensive care hospitals of the first and second level (the type and parameters of the hospital, its territorial location and capacity, etc.) is determined by the value of the implementation and the existing budget. At the same time, the implementation of the process of coordinating project configurations and their project environment PCP requires modeling them. This will make it possible to determine the rational parameters of the configuration objects (the type and capacity of the hospital, its territorial location, material resources and the number and qualifications of medical staff, etc.), which will ensure the receipt of products of projects for the creation of intensive care hospitals of the first and second level with the maximum value for stakeholders. The third stage of project portfolio management involves the implementation of a number of management processes PRIII , which ensure the formation of an effective portfolio of projects for the creation and development of hospital districts:
PRIII : PDK PIA PSM PAV PCP PPA PFP . (7)
Based on the results of service processes of database and knowledge formation PDK , as well as intellectual analysis of the existing state of the territorial healthcare system PIA , additional processes of assessing the value of individual projects PAV and the systemic value of the portfolio of projects PSV for the creation and development of hospital districts are performed. The results of the processes PAV and PSV , as well as the main process of coordination of project configurations and their project environment PCP ensure the implementation of the main process of coordination of the architecture of hospital district development project portfolios PPA .
During the execution of the specified process, the formation of individual variants of the portfolio architecture of projects for the creation and development of hospital districts, the number of which depends on the number of possible projects for the creation of intensive MultiCare hospitals of the first and second level, which are included in the composition of the specified portfolio is carried out [48-49].
The result of the main process PPA of aligning the architecture of portfolios with the configuration of projects for the creation of intensive MultiCare hospitals of the first and second levels is the determination of their types and quantities, which under the predicted changing project environment will provide maximum value for stakeholders. Based on the results of the process PPA , the main process of forming an effective portfolio of projects for the creation and development of hospital districts PFP is carried out, a set of projects (portfolio architecture objects) and their priorities are established.
At the fourth stage of management of portfolios of projects for the creation and development of hospital districts, management processes PRIV , which ensure the formation of a plan for the implementation of the specified portfolio are performed
PRIV : PIA PJA PSV PAC PBP PPI . (8)
Based on the results of the service processes of the intellectual analysis of the existing state of the territorial healthcare system PIA and the justification of the feasibility of changes in the architecture of the project portfolio PJA , additional processes of assessing the systemic value of the project portfolio PSV and their changes PAC are performed. The results of the processes PSV and PAC , as well as the main process of project portfolio balancing PBP , ensure the implementation of the main process of creating a plan for the implementation of a portfolio of projects for the creation and development of hospital districts PPI . As a result of the implementation of the main process PPI , plans for the implementation of projects for the creation of intensive MultiCare hospitals of the first and second levels and their portfolio are substantiated. At the same time, the creation of a plan for the implementation of a portfolio of projects for the creation and development of hospital districts is a dynamic process and it is carried out cyclically, taking into account changes in the changing project environment, which determines the feasibility of changes in the architecture of the project portfolio and the implementation of the corresponding additional process PAC .
The final fifth stage of managing portfolios of projects for the creation and development of hospital districts involves management processes PRV which ensure the implementation of the portfolio and its constant monitoring and control:
PRV : PJA PAC PPI PMC . (9)
Based on the results of the service process of justifying the feasibility of changes in the architecture of the project portfolio PJA , an additional process of evaluating changes PAC is performed. At the same time, on the basis of the main process PPI (plans for the implementation of projects for the creation of intensive MultiCare hospitals of the first and second levels and their portfolios), the processes of project portfolio implementation PID and their monitoring and control PMC are systematically implemented. The main process of monitoring and controlling portfolios of projects for the creation and development of hospital districts provides constant monitoring of the changing project environment and recording of its changes, which determine both the value of individual projects for the creation of intensive MultiCare hospitals of the first and second levels, as well as the systemic value of their portfolio. In addition, this process ensures quality control of the implementation of individual portfolio projects and the formation of their products. Based on the results of the main process PMC , there is a return to the service process of justifying the feasibility of changes in the architecture of the project portfolio PJA and the additional process of evaluating these changes PAC . If there is a deviation from the planned value, the main process PPI of adjusting the plans for the creation of intensive MultiCare hospitals of the first and second levels and their portfolios is carried out. Moreover, based on the results of the process PPI , there is a return to the process and coordination of the portfolio architecture of hospital district development projects.
We performed an analysis of the strategy of development of territorial healthcare systems of Ukraine. It has been established that the National Health Reform Strategy for Ukraine for the period 2015-2020, as well as in the Draft of Strategy for the Development of the Healthcare System until 2030 specify indicators for assessing the value of medical reform. These include ensuring an increase in life expectancy by 3 years, namely for men and women to 70 and 80 years, respectively, a reduction in maternal and child mortality (7.4%) to the EU average (3.7%), a third reduction in mortality from non-infectious diseases, reduction of the level of disability, reduction of morbidity and disability from various types of disease, etc. At the same time, healthcare system reforms began in 2017 and continue to this day in Ukraine. In November 2019, the Cabinet of Ministers of Ukraine approved the procedure for creating hospital districts with changes in June 2020 [45-47]. This order provides for the creation of hospital councils as advisory services under regional councils. Currently, hospital districts have been created in each of the regions of the state. Based on the analysis of the resolutions of the Cabinet of Ministers of Ukraine regarding the creation of hospital districts in certain regions and the indicators of the created administrative-territorial units on the territory of the state, we assessed the current state of their creation in certain regions of Ukraine. This made it possible to build a histogram of the number of created hospital districts in the section of individual regions of Ukraine and trends in the specific number of administrative districts per hospital district (Figure 2).
It was established that in three regions of Ukraine (Zakarpattia, Lviv and Kharkiv) there is a high ratio of the specific number of administrative districts per one hospital district. This is explained by the fact that only one hospital district was created in each of the specified regions. At the same time, in the majority of regions, the specific number of administrative districts per hospital district is within 1...2 units. We performed an analysis of the indicators of the specific population and area of the territory falling on one hospital district, in the section of individual regions of Ukraine (Figure 3).
It was established that the situation is similar with the indicators of the specific number of population and area of the territory falling on one hospital district in the section of individual regions of Ukraine (Figure 3). In particular, in the Zakarpattia, Lviv and Kharkiv regions, high values of the specific population and territory area per one hospital district are observed. The specific population of one hospital district exceeds the average values by 2.1 times in Zakarpattia region, by 4.3 times in Lviv region and by 4.5 times in Kharkiv region. According to the specific area of the territory included in one hospital district, there is an excess of the average values by 1.6 times in Zakarpattia region, by 2.7 times in Lviv region, by 3.9 times in Kharkiv region. All of the above indicates the need for a more detailed analysis of the creation of hospital districts in individual regions.
For further identification of contradictions in territorial healthcare systems, we selected the Lviv hospital district, which is one of them in the territory of the Lviv region (Figure 4).
Based on the analysis of the state of creation of the Lviv Hospital District [
In particular, there is a contradiction with the approved Procedure for the Establishment of
Hospital Districts [
The obtained results of the conducted studies indicate that the reform of the healthcare system in Ukraine is being carried out with many errors due to the chosen approach to management.
It is expedient to use the proposed adaptive value management of portfolios of projects for the creation of hospital districts in Ukraine, which will make it possible based on the developed conceptual model to systematically perform management processes and ensure the implementation of project portfolios for the creation and development of hospital districts with maximum value for stakeholders and adaptation to their specific project environment. Further research should be conducted in the direction of the development of models, methods, and algorithms for the implementation of management processes specified in the conceptual model, which belong to the methodology of adaptive value management of portfolios of projects for the creation of hospital districts. 6. Conclusions
1. The proposed conceptual model of adaptive value management of project portfolios for creating and developing hospital districts involves five stages, at which ten main, five auxiliary, and four service processes are systematically performed. The determined relationships between management processes and their results are the basis of the formulation of management tasks and the development of mechanisms for their solution.
2. The assessment of the existing state of the creation of hospital districts in Ukraine shows that in some regions there are high values of the indicators of the specific population and the area of the territory falling on one hospital district. 2. All of the above indicates the need for a more detailed analysis of the creation of hospital districts in individual regions. To identify contradictions in territorial healthcare systems, we chose the Lviv hospital district, which is the only one in the territory of the Lviv region. It was established that under the existing configuration of the Lviv Hospital District, part of rural communities remains medically protected.
3. The obtained results of the conducted research indicate that the reform of the healthcare system in Ukraine is being carried out with many errors due to the chosen management approach. It is expedient to use the proposed adaptive value management of portfolios of projects for the creation of hospital districts in Ukraine, which will make it possible to systematically perform management processes based on the developed conceptual model. Further research should be conducted in the direction of the development of models, methods, and algorithms for the implementation of management processes specified in the conceptual model, which belong to the methodology of adaptive value management of portfolios of projects for the creation of hospital districts. 7. References [16] S. Bushuyev, N. Bushuyeva, D. Bushuiev, V. 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