An effective contract in healthcare: motivation of employees or the problem of managers. An effective contract in healthcare: the pros and cons of the new system

The use of an effective contract for health workers is designed to bring the quality of services to a new level and increase the interest of workers in achieving high performance. For this purpose, special criteria for an effective contract (in health care) are established for health workers. In fact, the introduction of an effective contract allows you to establish a direct relationship between the quantity and quality of work performed by an employee and the amount of remuneration of a particular employee.

The basic task for health care is to improve the quality of services for the population in the coming years. To achieve the goal, it was decided to move from estimated financing to a more advanced system of remuneration - an effective contract in healthcare. The amount of incentive payments, salary, labor assessment criteria - these indicators will affect the level of income of medical personnel. Officials are confident that the transition to effective contracts in healthcare will improve working conditions for staff, improve the quality of services for the population and stop the outflow of qualified personnel.

Tasks and criteria for an effective contract in healthcare

The concept of an effective contract has been present in the legislation for quite a short time. It was introduced by order of the Government of Russia dated November 26, 2012 No. 2190-r. This normative act approved a special program, in accordance with which a gradual improvement in the procedure for remuneration of employees of budgetary institutions will be carried out.

In order to increase the efficiency of the work of employees and motivate them to achieve maximum professional results, conditions on special incentive payments are introduced into the employment contract. At the same time, such payments are made only when the employee reaches the indicators stipulated by the contract.

In this regard, information on the list of incentive payments established in relation to each specific employee is entered into an effective contract. In addition, the indicators are clearly prescribed, upon reaching which the employee receives contractual payments.

Most often, to introduce performance indicators, the current labor contract with the employee is supplemented with special provisions, which include the criteria for an effective contract in healthcare. For this purpose, an additional agreement is concluded to the current employment contract, which lists performance indicators, incentive payments and their size.

You can download an effective contract in healthcare on our website. Here we bring to your attention an additional agreement to the employment contract, which contains information specific to an effective contract. Such an additional agreement to an employment contract (an effective contract in healthcare sample)

Sample effective contract in healthcare

An effective contract is a new type of employment agreement that clearly defines the responsibilities of each employee. An effective contract in healthcare will change the attitude of employees to their duties and improve the level of services provided to the population. The task of the reform is to analyze the work of both an individual specialist and the entire medical organization. The main goals of the state program:

• Maintain human resources.
• Ensure decent wages in every medical organization.
• Raise the prestige of the profession.
• Significantly improve the quality of services.
• Encourage employees to improve their skills.

To achieve the goals in the new employment contract, special attention is paid to the section "Payment". An effective contract in healthcare provides for several types of payments:

• Rate and salary.
• Compensatory payments - allowances for seniority, working conditions, etc.
• Incentive payments - in this paragraph, the developed system of criteria for assessing personnel is fixed.

Please note that the incentives are not permanent. In order to receive them, the employee must fulfill certain conditions, have no complaints from patients, follow the established plan, etc.

A sample of an effective contract in healthcare can be supplemented with other conditions:

• Introduction of a point system for assessing work.
• Cash reward for an overfulfilled plan (for example, conducting medical examinations, etc.).
• Specification of job responsibilities for each employee.
• Periodicity of payments.

Transition to efficient contracts in healthcare

Reforms are always scary, but an effective contract in healthcare is the same labor contract. The main difference is that all job responsibilities will be spelled out in the document. The transition to an effective contract in healthcare requires compliance with certain conditions:

Step 1. Preparation and delivery of the notice to each employee.

At least 2 months before the transition to a new remuneration system, the manager must familiarize the staff with the innovation (under signature).

Step 2. Development of an additional agreement to the current employment contract.

Here are the new working conditions. Since there will be many changes, the parties "agree" on a new version of the agreement.

Step 3. Issuance of an order (effective healthcare contract).

The document informs about the transition to a new system of remuneration.

If the employee does not agree to continue working under the new conditions, he may be dismissed under clause 7 of part 1 of Art. 77 of the Labor Code of the Russian Federation.

Further, a commission is being created, which will form the criteria for assessing personnel according to certain indicators. Local acts of the organization are being developed and amended - a collective agreement, internal labor regulations, job descriptions, regulations on remuneration.

The employer must specify a deadline for the transition of the entire organization to an effective contract in healthcare.

Prerequisites for reform - why is it necessary to switch to an efficient contract in healthcare?

An effective contract in healthcare is necessary to improve the wage system: each employee receives incentive payments by providing quality services. The most important tasks became the prerequisites for the reform:

• Implementation of the national project "Health" - additional payments to health workers.
• The regional modernization program is the introduction of high standards of services and improving the quality of medical care.

During the analysis of the existing system of remuneration in health care, it was found that it is not effective. Employees receive various allowances, salaries, payments for harm. But there are no incentive payments for the quality of services and personal achievements. An effective contract in healthcare will change the very mechanism of payroll, motivating employees to improve their skills, honing their professionalism.

The transition to effective contracts in healthcare is a complex process only in organizational terms. But such an approach will make it possible to increase the level of income of employees and introduce new quality standards for the provision of medical services.

In this issue, we will tell you what risks health facilities face in practice after switching to an efficient contract.

Goals and objectives of an effective contract

The Program for the gradual improvement of wage systems in state (municipal) institutions, which was approved by the Government of the Russian Federation on November 26, 2012, set clear goals:

• maintain human resources;
• increase the prestige of work in budgetary medical institutions;
• bring the remuneration of medical workers in line with the level of quality of work performed by them.

To achieve these goals by 2018 in the healthcare sector, a number of tasks must be solved:

Disadvantages and advantages

While there is much to be gained from the idea of ​​an effective contract, the likelihood of risks must be taken into account when putting it into operation. Especially at the initial stage of work in the conditions of the new wage system, when many questions arise regarding how much money and for what exactly the employees of health facilities will receive.

“It was supposed to organize the payroll system in such a way that both the complexity of the work and its quality were taken into account,” says Alina GALIULINA, project manager at SKB Kontur. — But for this it is necessary to solve the problem of the structure of wages. So far, all the proposed systems for evaluating the work of physicians have a number of shortcomings. Initially, the idea was to introduce performance criteria for each position, such as a point system. Each indicator for each specialty is evaluated in points. Then the employee's points are summed up, multiplied by a certain constant, and the received amount is paid to the person. Everything seems to be logical, but this option is bad because every month you need to count the points (and there can be several hundred employees in the health facility), submit this data to economists, and they must calculate the size of the allowances in a short time. This is simply unrealistic, to calculate points you need a department or at least one employee who will only deal with this. ”

Therefore, many health facilities, in order to avoid a huge amount of work with scoring, introduced a system of coefficients and faced a deficit in the wage fund. This happened partly because the payroll was not designed for 100% fulfillment of the plan by all employees, and partly because of the general underfunding of the healthcare sector.

According to the Accounts Chamber of the Russian Federation, in 2014 the shortage of funds in the healthcare sector amounted to 55.3 billion rubles due to compulsory medical insurance.

According to Irina TITOVA, head of the personnel department of Krasnoufimskaya RB, their medical institution had many problems with payment. Despite the fact that according to the roadmap, the basic and incentive parts of payment should be 60 and 40%, respectively, in practice, everything is far from being the case and the basic part is much less. So it is not quite clear yet how to achieve the level of wages, which is provided for by the order approved by the President of the Russian Federation.

However, at the same time, Irina TITOVA notes the advantages of paying part of the salary in accordance with the criteria for assessing work: this encourages employees to complete their tasks 100%.

“With the introduction of the new remuneration system, the efficiency of the work of the staff has increased, the efficiency has increased,” says Elena SERMYAGINA, Head of the Human Resources Department of the Sverdlovsk Regional Clinical Hospital No. 1. — Of course, a large amount of work has been added for personnel officers and economists. And we need to continue to analyze the effectiveness of an effective contract, but so far we have not particularly noticed any minuses. And to date, much more systematic work is expected, which justifies the essence of the introduction of effective contracts. There are still many organizational measures to be taken, but in the end, an effective contract will indeed be effective in the full sense of the word. And then the person will know for what and for what he works, the quality of his work and his attitude to work will become better. I do not see anything negative in the introduction of an effective contract. It's just that everything new is perceived with caution by people, and there are always those who do not accept the new, they like to live in the old way.

In some healthcare facilities in the Sverdlovsk region, the transition to an effective contract has occurred quite recently, but due to underfunding, one can hardly expect any positive changes.

“Yes, they renamed the employment contract, expanded it, put duties in it,” says the head of the personnel department of one of the district hospitals. - But if there is no money, then this is just another government profanity. Maybe some healthcare facilities have improved the situation due to the reduction of key positions when introducing an effective contract, but not all of them. But new responsibilities for personnel officers are falling like a snowball, reporting has increased four times.”

Possible Solution

Regional departments do not give a clear answer on what to do if there are not enough funds to pay the incentive part of the salary. Therefore, personnel officers and economists of various health facilities are trying to find a way out of this situation on their own.

The Karpinsky Central City Hospital also faced a shortage of payroll, and, as Tatyana VASILYSHINA, head of the personnel department, says, they had to talk with employees, explain the situation, for what reason the amounts received were less than expected, and also introduce new agreements to the payment agreement every month. All this, of course, adds paper work to personnel officers.

In turn, in GBUZ SO "Malyshevskaya GB" the introduction of a directly effective contract did not cause economic turmoil, but the subsequent cuts in hospital funding for 2015 also put the economists of health care facilities into a dead end.

“Alternatively, it is necessary to make initially a small coefficient for incentive payments in order to meet the planned payroll. But how can you predict in advance how the employee will fulfill the plan? - says Alina GALIULINA. - Therefore, now the majority of medical institutions conclude effective contracts either with vague wording, or without prescribing indicators at all. But then any test will reveal that there is no point in concluding an effective contract. The best way is to calculate the correct ratio by analyzing the work under the conditions of an effective contract for six months. It takes a lot of effort and time."

For Russian healthcare, 2014 was marked by a number of important changes. From January 1, medical institutions began to switch to a new system of remuneration for workers - an effective contract. Like most other reforms, this innovation still raises questions and concerns among many organizations. However, in practice it has already been proven that everything is not as scary as it seems at first glance.

First steps towards effective medicine

For Russian healthcare, 2014 was marked by a number of important changes. From January 1, medical institutions began to switch to a new wage system workers - effective contract. Like most other reforms, this innovation still raises questions and concerns among many medical organizations. However, in practice it has already been proven that everything is not as scary as it seems at first glance. Consider an example of how to compose according to the new rules employment contract in a medical institution, install duties of doctors, define criteria for evaluating the effectiveness of personnel activities, assign incentive payments and reflect changes in the system automation of personnel records.

Employment contract in a new way

The President of the Russian Federation in his budget message dated June 28, 2012 formulated the basic task in the healthcare sector for the coming years: to improve the quality of state and municipal healthcare services. To achieve this goal, it was decided to move from the estimated financing of institutions to the introduction of a new payment system - an effective contract. This is an employment contract that specifies the duties of a health worker, terms of remuneration, indicators and criteria for evaluating the effectiveness of activities for assigning incentive payments depending on the results of work and the quality of state (municipal) services provided, as well as social support measures.

Officials are confident that the transition to a new wage system will attract qualified specialists to state and municipal medical organizations and eliminate the outflow of personnel to private medical organizations. According to the head of the Ministry of Health of Russia Veronika Skvortsova, in Russia there is a shortage of nursing staff of 270 thousand people, and doctors - about 40 thousand.

Since the beginning of 2014, some medical institutions have already switched to a new wage system. Of course, this cannot be done in one day: you have to prepare the relevant documentation, as well as make a number of changes to the HR automation programs.

Ural pioneers: effective contract in practice

Yekaterinburg City Children's Hospital No. 5 was one of the first to master effective contracts. Now the doctors of MBU Children's City Hospital No. 5 (there are more than 100 of them) have been transferred to the new wage system. With all newly hired doctors, the medical institution also concludes an effective contract. This transition was not easy. The direct participants of the event - the head physician, the heads of the structural divisions of the hospital - invested a lot of effort and faced a number of difficulties.

First of all, we drafted a notification for healthcare workers about upcoming changes and attached an additional agreement to the employment contract to the new document. Thus, in accordance with Article 72 of the Labor Code of the Russian Federation, all hospital employees were aware of the innovations two months before the changes came into force. In order not to reinvent the wheel, the employment contract (effective contract) can be found in the section of the electronic journal "Accounting in budgetary institutions". If required, the institution has the right to slightly change the content of the document. For example, the management of MBU Children's City Hospital No. 5 made minor changes to the "Job Responsibilities" section and to the "Payment" item. For each doctor, the following was clarified and specified:

• official duties;
• indicators and criteria for evaluating the effectiveness of activities;
• the amount and conditions of incentive payments, determined taking into account the recommended indicators.

Criteria for evaluating effectiveness: instructions for use

The definition of criteria for evaluating the effectiveness of medical workers caused the most difficulties. To resolve this issue, the hospital created a commission, which included the heads of structural divisions. For example, in determining the criteria for evaluating the activities of hospital workers, the deputy chief physician for medical work took part in the work of the commission, and if it was a question of polyclinic workers, then the deputy chief physician for outpatient services. Or managers together developed criteria for evaluating performance and passed it to the personnel department for consideration. As a result, five to seven criteria for evaluating the effectiveness of doctors' activities were determined for each specialty.

The basic principle in the development of performance indicators for medical staff to determine the amount of incentive payments is that the procedure and conditions for their establishment are clear to the employer and employee. In particular, for the department of laboratory diagnostics, it was determined that the fulfillment of planned volumes while maintaining the availability of medical care under the state guarantees program up to 100 percent is 0 points (no incentive payment), from 101 to 103 percent - 1 point (2000 rubles), more 103 percent - 2 points (4000 rubles). Or another example - conducting preventive examinations of minors, including a general analysis of blood, urine, sugar: less than 95 percent - 0, more than 95 percent - 1 point, more than 100 percent - 2 points, and so on. Thus, when the plan is overfulfilled, health care workers, in addition to the guaranteed payment (salary and allowances for the position, length of service, category, harmfulness), receive from 20 to 28 thousand rubles. incentive payments. The specific amount depends on the specialization of the doctor and the degree of implementation of the planned scope of work.

Two commissions were involved in scoring at MBU Children's City Hospital No. 5. The first group includes heads of departments. They review the performance of health workers and assign scores for each performance evaluation criterion. Then the doctors sign the protocol, confirm that they agree with the amount of the incentive payment or with its absence. This document is transferred to the commission of the second level, where the head physician, chief economist, chief accountant and head of the personnel department approve it and submit it for payment.

Incentive payments: every number in its place

It was not easy to immediately master the avalanche of new data: performance evaluation criteria, points, percentages. It was necessary to carry out individual explanatory work with healthcare workers, to explain what the guaranteed amount is made up of, and what the incentive payments are made of. Separately, it was necessary to explain that the employee will receive the guaranteed amount in any case, and incentive payments - only if the plan is overfulfilled.

The introduction of an effective contract in a medical institution will be calmer if individual information work is carried out with each of the employees. Even at the stage of creating a notification for employees, the personnel department prepared two tables for clarity, in which they described in detail the criteria for evaluating activities, that is, how much money and for what exactly the doctor receives. When preparing appendices to agreements under an effective contract, we strictly followed the recommendations of the Russian Ministry of Health: all data was included in one table. But the employees already understood where and what figure comes from.

The first two months from the date of the introduction of an effective contract in MBU Children's City Hospital No. 5, there was an adaptation period: medical workers were not fined for failure to comply with the plan, allowing them to get used to the new system. But since May 2014, penalties began to operate.

Efficient contract and automation of personnel records

The activity of personnel officers of medical institutions is now automated. Therefore, for the transition to an effective contract, it is necessary to prepare not only the documentation and personnel of medical institutions, but also programs for automating personnel records. In MBU Children's City Hospital No. 5 they use the "Kontur-Personal Medicine" system. Effective contracts require customization of the program, so the medical institution turned to an accompanying specialist from the development company. Hospital personnel officers indicate their job responsibilities in the "Employment Units" section. For example, they create the position of “pediatrician” and put all the duties there so that they are automatically pulled into the contract.

You can also configure the program on your own, following the step-by-step recommendations of the developers. They are quite versatile, we will give them below.

Step 1. It is necessary to set up incentive payments based on the results of labor activity. The program has a special directory containing a list of these payments. For each, you need to put down the conditions for obtaining. For example, for a payment for the absence of valid complaints, the conditions may be as follows:

• lack of justified complaints - 1 point;
• 1 or more justified complaints - 0 points.

If there are not enough payments in the directory, you can add them. In this case, the setup will be done by an accompanying specialist (developer employee).

Step 2. It is necessary to indicate in the staffing table information about what types of incentive payments are due to each staff unit. To do this, in a special attribute in the staff unit card, you need to select from the directory (the setting of which is described in step 1) the types of payments due. Opposite each such payment, you must indicate the cost of one point in rubles and the frequency of payments.

Step 3. In special details in the card of the staff unit, it is desirable to indicate the reasons for the cancellation of payments and a list of job responsibilities. Then later on you won't have to manually type this information in the form of an effective contract.

The transition of the hospital to an effective contract requires even more care and responsibility from personnel officers than the previous mode of operation, especially when hiring a person. The HR specialist needs to clearly know what criteria correspond to the position being entered and where to get them.

It is necessary to carefully enter the job responsibilities of an employee and enter the corresponding performance criteria into the program. Even if the HR program (in the "Payment" section) contains all the criteria for evaluating activities, you still need to choose the right one. After all, if you enter the wrong criterion, there may be negative consequences. Suppose an employee has already read the contract and signed it, and then it turns out that he was fined for something that is not in the contract. Experience shows that it is very useful if each employee of the HR department always has a list of criteria with points and amounts at hand on their desktop. Then, when filling out the documents, it will be possible to quickly check everything.

See also:
- Efficient contract
- Tax incentives for budgetary institutions
- Remuneration systems of budgetary institutions 2014
- The system of remuneration of state employees 2014
- Wage increase

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Until recently, domestic legislation did not contain not only a sample of an effective contract, but also the very concept of such an instrument. However, with the adoption of the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012 - 2018, approved by Decree of the Government of the Russian Federation of November 26, 2012 N 2190-r, this mechanism for formalizing labor relations appeared in domestic practice.

Effective employment contract

The Government of the Russian Federation, by its decree, defined an effective contract as an employment contract that has specific and understandable criteria for evaluating the work of an individual employee in order to accrue incentive payments.

It should be borne in mind that the transition to this type of registration of legal relations with employees must be carried out in strict accordance with the requirements of the Labor Code of the Russian Federation.

Moreover, the domestic legislation currently in force allows the transfer to effective contracts only of employees of state and municipal organizations.

Employees of private enterprises cannot be transferred to this form of registration of relations.

Each employer, when introducing this type of agreement, must perform the following steps:

• specifically define the duties and functions of each employee of the enterprise;
• develop criteria for evaluating the effectiveness of labor activity;
• to agree not only the level of payment, but also incentives;
• obtain the consent of the employee to switch to a new type of contract.

An approximate sample of an effective contract (employment contract) is approved in the above Order of the Government of Russia. Its form can be obtained using the legal reference system "Consultant Plus" or downloaded from the websites of the authorities of the Russian Federation.

It is important to remember that the ultimate goal of transferring employees to an effective wage system is to achieve a balance between the amount of income and the complexity of the functions performed by the employee.

Effective contract after 2018

Currently, the end date for applying an effective approach to remuneration of civil servants is 2018.

However, the Government of the Russian Federation did not indicate the termination of its program after such a date.

For the period of 2017, it is planned to analyze the implementation of the initiative and develop recommendations for its further use.

Taking into account the stated goals, it can be assumed that even after 2018 the institution of an effective contract will not disappear from the domestic practice of registering civil servants for work.

Effective employment contract: sample

It should be emphasized that the Government of the Russian Federation approved only an approximate form of an effective labor agreement.

Each state and municipal structure has the right to develop its own version of such a document used to transfer employees to an effective method of remuneration.

However, given the relative novelty of such a tool, it is reasonable to use the developed form.

When introducing the specified system of remuneration of employees, the employer must apply the following types of registration of new relations:

• at the initial employment - to conclude an appropriate contract;
• to transfer existing employees, it is necessary to resort to the help of additional agreements to existing contracts.

Ignoring this algorithm will not allow you to correctly transfer workers to an effective wage system. The new conditions simply will not apply to the relevant employees.

Sample effective contract

An effective contract in healthcare: opportunities and risks

From the editor:

As we promised, we continue to publish materials related to an effective contract in healthcare. This topic is much broader than the issues of remuneration of health workers. Today's material is devoted to the opportunities and threats associated with the implementation of an effective contract, proposals to counter existing risks and threats. In the next issues of the journal, we will continue the topic: materials will be published on the regional aspects of the implementation of an effective contract, analysis of various wage systems, etc. We invite our readers to join the discussion of the issues raised.

Chief editor N.G. Kurakova

Measures related to the implementation of an effective contract are becoming increasingly specific. Along with the well-known*(1), there are more and more new documents devoted to this topic. It is worth mentioning, for example, the Action Plan ("road map") "Changes in the sectors of the social sphere aimed at improving the efficiency of healthcare", approved by the Order of the Government of the Russian Federation of December 28, 2012 N 2599-r. The purpose of this "road map" is to improve the quality of medical care based on improving the efficiency of medical organizations and their employees.

In pursuance of this resolution, a number of orders of the Ministry of Health of Russia were issued, including Order No. 1706 dated December 29, 2012 "On approval of guidelines for the development of action plans ("road maps") by the executive authorities of the constituent entities of the Russian Federation "Changes in social sectors aimed at Improving the efficiency of health care in the subject of the Russian Federation".

We see that the measures related to the introduction of an effective contract have gone far beyond issues directly related to the remuneration of employees: these are issues of labor legislation, and labor rationing, and the quality of medical care, and the efficiency of health care institutions in general, etc. d.

One can only welcome the main measures related to the introduction of an effective contract. The mere fact that the increase in wages is not seen as an end in itself deserves a positive assessment - the task is to get a serious return from this in the form of improving the availability and quality of medical care. And the emphasis on the phrase "effective" in relation to the contract is not accidental - within the framework of the current labor legislation and the accepted forms of employment contracts, it is easy to implement only positive incentives (encouragement). It is extremely difficult or even impossible to establish a strict demand from employees, to reduce pay for poor-quality work.

It can also be assessed as the right decision that the introduction of an effective contract is carried out simultaneously with an increase in the general level of remuneration, provided for by Decree of the President of the Russian Federation of May 7, 2012 N 597 "On measures to implement state social policy" (hereinafter referred to as the Decree of the President). Indeed, it is difficult to make serious demands on the volume and quality of work with the existing rather low level of remuneration of medical workers. An increase in the general level of remuneration creates good prerequisites for increasing demand from medical personnel for the results of their work. On the other hand, wage increases in and of themselves do little: if you simply increase the wages of employees, for example, by 2 times, they will not start working twice as well - adequate measures of responsibility are needed. The simultaneity of these measures makes it possible to break the existing "vicious circle".

Nevertheless, attempts at a "one-time" transition to an effective contract can be fraught with negative consequences. It is necessary to take into account not only the prevailing mentality of medical workers ("all-round defense" when trying to increase demand for the results of work, blackmail with layoffs - after all, the personnel problem will not be solved overnight after the introduction of an effective contract, etc.). Wages must also be taken into account. If we look at the dynamics of approximate (indicative) values ​​of the ratio of the average wages of health care workers and the average wages in the constituent entities of the Russian Federation in 2012-2018 * (2), then we will see that until 2015 the pace of wage increases is rather modest - a significant jump wage growth is expected only in 2016-2017*(3). This "delay" is no coincidence. First, by 2015, the financially costly step-by-step increase in the amount of insurance premiums for insurance of the non-working population paid by the constituent entities of the Russian Federation should be completed (before this period, it is possible to pay not all of the Federal Law of the Russian Federation of November 30, 2011 N 354-FZ "On the amount and the procedure for calculating the rate of insurance premium for compulsory medical insurance of the non-working population "an insurance premium in the amount of 18,864.6 rubles per non-working person per year). A simultaneous increase in the wages of state employees would be unbearable for a number of regions. Secondly, there are hopes that the economic situation in the country will improve by the specified date.

But one way or another, taking into account the existing realities, in our opinion, it is not advisable to introduce tightening requirements for medical workers in full at once - this process should be phased and generally correspond to the growth rate of their wages. The situation when, with a nominal increase in wages by 5-7%, measures are introduced that provide for the possibility of a much larger (even if justified) reduction in wages, can be perceived extremely negatively.

It should be recognized that, unfortunately, at one time a number of unique opportunities were missed to establish the dependence of wages on performance results, including the quality of medical care. An excellent potential opportunity to take into account the resulting indicators in wages arose with the introduction of additional payments to employees of the district service and ambulance, paramedics within the framework of the priority national project "Health". Moreover, a phased transition to establishing the dependence of wages on the results achieved could be ensured. Officially, it was believed that, for example, additional payments to employees of the district service (10 and 5 thousand rubles) are made for the fulfillment of "the state task for the provision of additional medical care." Employment relations between these employees and healthcare institutions for the performance of additional work in connection with the implementation of the state task for the provision of additional medical care were formalized by concluding additional agreements to employment contracts. The contracts provided for the imposition on the employee of obligations to perform an additional amount of work within the limits of the working hours established by him by law, depending on the position. For the performance of additional duties, employees were given an additional payment in the form of a stimulating bonus to wages. It was assumed that failure to fulfill these obligations could serve as a basis for the reduction or complete removal of additional payments. However, it turned out that under no circumstances could these payments be reduced - it was impossible to financially punish employees for failure to fulfill additionally assigned duties. Accordingly, the expected effect in the form of improving the provision of medical care from the introduction of these payments was not obtained (although the task of retaining personnel was partially solved). Thus, this unique opportunity to link at least part of wages to the results of labor was not realized.

It should be noted that now funds for these purposes are received within the total amount of subventions allocated to the territorial funds of compulsory medical insurance from the federal fund. That is, the constituent entities of the Russian Federation have the right to independently determine the amount and conditions for making these payments, including making decisions to reduce the amount of payments if the established requirements are not met.

There is hope that now the chance to link increased wages with performance will not be missed.

Moreover, there are good prerequisites for the implementation of an effective contract. First of all, these are new conditions for the operation of state (municipal) institutions in connection with the ongoing reform of the public sector as part of the implementation of Federal Law No. (municipal) institutions.

The Budget Address of the President of the Russian Federation dated June 28, 2012 on budget policy in 2013-2015 noted: "The legal framework for refusing the estimated financing of institutions and introducing a new wage system has already been created. Now the task is to introduce it everywhere and ensure practical implementation a new mechanism for financing state and municipal institutions already provided for by law, and in the institutions themselves - to ensure the transition to an "effective contract", which should clearly define the terms of remuneration and the "social package" of the employee, depending on the quality and quantity of the work performed by him. contract" is also designed to increase the competitiveness of the state as an employer in regional labor markets and the comparability of labor costs in the state, municipal and private sectors of the economy.

Among the provisions of the mentioned new legal and regulatory framework created as part of the reform of the public sector, the following points can be highlighted that contribute to the implementation of an effective contract:

State (municipal) health care institutions, by virtue of the abolition of the subsidiary liability of the owner for the obligations of autonomous and budgetary institutions, the expansion of the types of property for which they are liable for their obligations, the increase in the personal responsibility of managers for the presence of overdue accounts payable, etc., become not just interested - they become forced to carry out their activities more effectively;

The role of income from income-generating activities, which involves the use of other, more efficient wage systems, is increasing;

The independence of institutions is increasing in many areas, including in matters of remuneration, etc.

A good prerequisite for the implementation of an effective contract is the experience of implementing modernization programs in healthcare, within which certain experience has been gained in developing criteria for evaluating the work of a number of categories of medical workers. Another thing is that in the framework of the implementation of modernization programs, the real binding of wages was not always carried out. Insurance organizations, in accordance with the supplementary agreement to the contract, could withdraw from the institution an additional part of the tariff provided for the implementation of the standard in cases where the standard was not fully implemented. But, firstly, within the institutions, there was usually no link between the additional remuneration of an employee and the amount of payment received for the treatment of a particular patient. And, secondly, the reduction by the insurance organization of payment for the rendered medical services was not directly related to the quality assessment - the insurance organization could remove an additional part of the tariff for the very fact of non-compliance with the standard, regardless of how much it was necessary to fully comply with the standard in this particular case, taking into account the state the patient's health, the presence of concomitant diseases, etc.

As already noted, an effective contract contains a number of positive ideas, provisions, opportunities for improving the functioning of health care. But it is necessary to take into account the possible threats associated with the process of implementing an effective contract in order to prevent them as far as possible.

In particular, in accordance with the Order of the Government of the Russian Federation of November 26, 2012 N 2190-r "On approval of the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018" (hereinafter referred to as the Order), the calculation of the actual level of average wages for certain categories of employees, in relation to the average wage in the corresponding subject of the Russian Federation, is calculated per 1 individual (based on statistical data on the number of employees). At the same time, the amount of accrued wages of employees on the payroll for the main job includes remuneration for internal part-time work, as well as remuneration under civil law contracts concluded by employees on the payroll with their institution. It is well known that in healthcare there is a high level of part-time work and the performance of additional work that, according to the law, does not belong to part-time work, but, in fact, corresponds to it. The methodology approved by the Decree compares the salary of a medical worker working at 1.5-2 rates with the salary of an "averaged" worker for the region, working at about 1.25 rates. Therefore, many medical workers, having learned about the essence of the methodology, are disappointed, because due to part-time jobs, combining positions, additional duties, payment for the provision of paid services, etc. and present wages may be high enough not to be subject to serious further increases.

The same applies to the following provision of the Order: "When assessing the ratio of wages of certain categories of workers, determined by the Decree of the President, and the average wage in the region, all wages received by the employee from all sources are taken into account." On the one hand, this is good - there will be incentives for the development of official paid services at all levels: from the heads of the constituent entities of the Russian Federation to the heads of institutions, there will be fewer unreasonable restrictions in this area. At the same time, this is a good prerequisite for reducing the shadow payment for medical care. But again, workers who provide official paid services (whether during regular or non-working hours) may feel deceived - after all, it is not the state that provides them with wage increases, but they themselves.

In view of all this, a good explanatory work is needed, designed to show real prospects for a wage increase (with all the reservations - a very serious one), without creating false expectations.

And although in any case, the increase in the salaries of medical workers will be significant, industry specifics should still be taken into account.

Further. Until now, there is ambiguity on many fundamental issues. In particular, this concerns the specification of which specific employees are subject to the measures to increase wages provided for by the Decree of the President. We are talking, for example, about doctors and employees of medical organizations with higher medical (pharmaceutical) or other higher education, providing medical services (ensuring the provision of medical services). "On the one hand, it is good that they have not forgotten (as happened in many cases ) workers with a higher non-medical education (for example, biological, pedagogical (speech therapists) or psychological education). But, on the other hand, it should be clearly defined what the phrase "provides the provision of medical services" means. Whether a statistician or methodologist? Will it be fair to deprive them of the salary increase provided for the main category of doctors. Does an engineer with a higher education servicing the pressure chamber belong to this category? Will nurses without medical education be entitled to a salary increase in accordance with the Presidential Decree (in accordance with with the new legislation, they do not apply to medicine nsk workers)? These issues are all the more relevant because, by and large, the task of any employee who does not provide direct medical care is to ensure the provision of medical services.

The specification of these provisions is also important from another point of view: the introduction of an effective contract should not be selective - it should apply to all public sector employees (selective measures should be taken in relation to various categories of workers, taking into account the characteristics of their work). The lack of interest in the overall results of the institution's activities of employees responsible for logistics (including medicines), maintenance of equipment, etc., can become a serious brake on measures to ensure the success of the implementation of an effective contract (more precisely, to achieve the expected results).

In this regard, we recall that, in accordance with the Decree of the President, it is planned to increase wages not only for doctors, nurses and junior medical personnel, but also "increase in wages for workers in the budgetary sector of the economy", although without specifying the increased level. Therefore, in order to avoid another distortion in the levels of remuneration of employees of health care institutions (which is one of the risks of introducing an effective contract), a more or less comparable increase in the level of remuneration of all employees is needed.

In this regard, I would like that in the future, both the constituent entities of the Russian Federation (municipalities) and institutions, would seek funds to increase wages not only for the categories of personnel provided for by the Decree of the President, but the inspectors, in turn, would not cling to the fact that in the stipulated The Presidential Decree increased the wages of employees who, in their opinion, were not entitled to an increase (so that this would not be considered as "misuse of funds", etc.).

Let's consider another important point. The order stipulates: "ensuring the differentiation of remuneration of the main and other personnel, optimization of expenses for administrative and managerial and auxiliary personnel, taking into account the maximum share of expenses for remuneration of their labor in the wage fund of the institution no more than 40%."

The need to optimize the cost of salaries for administrative and managerial personnel is beyond doubt - they are often overstated due to excessive numbers, unreasonably high salaries, etc.

An analysis of the experience of the regions shows that the main measures aimed at reducing the cost of maintaining other personnel usually include:

Normative setting of limit values ​​for the share of administrative and managerial personnel in the structure of regular positions of institutions (or in the wage fund);

Transfer of a number of economic functions to junior medical personnel;

Reorganization of health care institutions in order to reduce managerial staff;

Transfer of part of the functions of health care institutions to outsourcing.

However, unfortunately, not all of these measures provide a real positive effect. Thus, practice shows that outsourcing is an effective means to reduce the cost of remuneration of other personnel. But, as a rule, not an effective means in terms of saving the total costs of the institution is the transfer to outsourcing of a number of functions, such as: feeding patients in hospitals, cleaning, security, etc. in the general case, it leads not to a reduction, but to an increase in costs. Moreover, in relation to other functions transferred for outsourcing, there is no single general principle - everything is determined by the characteristics of the institution, the volume of services transferred, the market prices of performers, etc. It is worth adding that it is not difficult to meet the specified requirement to reduce the cost of administrative and managerial personnel through outsourcing. But it is necessary to prioritize correctly: regulation of the salary share of administrative and managerial personnel is a narrower (more particular) task than improving the efficiency of the institution as a whole. Failure to comply with the requirement under consideration within a particular institution (by the way, the Presidential Decree does not say that this requirement must be observed in relation to each institution) should not be a reason for repression in relation to the heads of institutions - an analysis of all circumstances is necessary.

But the most important thing is that health care institutions differ greatly in terms of equipment, occupied territories, methods of providing certain functions (somewhere washing, equipment maintenance, information support, etc. are carried out by the institutions themselves, and where -something under contracts with third-party organizations (the same outsourcing).Therefore, uniform templates are unacceptable.

Yes, the salaries of other staff should be in optimal proportion to the salaries of medical workers. But, paradoxically, with all the shortage of personnel in healthcare, it is often not medical workers that are most in short supply, but other personnel, especially those related to general industry specialties (positions): drivers, laborers, engineers, etc. It is the easiest for them to find work in other organizations, in other industries; it is they who sometimes create the main personnel problem. Moreover, this is usually a hidden, latent shortage - vacant positions for drivers, engineers, etc. often not so much. But since the ambulance will not leave without a driver, etc., institutions are forced to pay extra to these categories, so outwardly everything looks more or less safe. At the same time, in percentage terms, the "withdrawal" for other personnel is often much higher than for medical personnel. All this must also be taken into account when implementing an effective contract.

There are also many questions about the consistency of the provisions of the Order with the norms of not only labor, but also other legislation, with other regulatory acts relating to healthcare. In particular, in accordance with the Order, "the formation of the staffing of institutions is supposed to be carried out using labor rationing systems, taking into account the need for high-quality provision of state (municipal) services (performance of work)". There is no objection to such an approach. However, a natural question arises: what about the procedures for providing medical care, which provide for the recommended staffing standards? It is necessary to ensure the coherence of the regulatory framework on a number of issues.

Another important issue is the need to clearly define the salary structure. The current system of division into base salary, compensation payments and incentive payments has a number of shortcomings.

In particular, this concerns the guaranteed level of remuneration. Although legally it is the minimum wage, this, of course, does not mean that when fulfilling labor standards, the employee is entitled only to the minimum wage. When fulfilling the labor norm, the employee has the right to a salary in accordance with the accepted system of remuneration at the level established by the results of tariffication. The establishment of a closer dependence of the level of remuneration (at least in terms of incentive payments) on the results of labor raises the question of what should be included in the tariff (guaranteed part), and what will the employee receive in the form of additional payment for achieving the established indicators?

The other side of this question: what will be included in the concept of labor standards: only hours worked (with time-based systems) or will the concept of labor standards also include the achievement of a certain minimum level of qualitative indicators (for example, the volume of medical examination, morbidity rates)? Recall that, in accordance with labor legislation, failure to comply with labor standards can serve as a basis for reducing wages.

In other words, if incentive payments are made, for example, for exceeding the established level of medical examination, for a decrease (relative to a specific level) of morbidity, etc., will these types of incentive payments be included in the billing or not?

This question is extremely important - after all, a number of other questions depend on it:

What level of wages is included in the tariffs in the CHI system (will incentive payments be included if they are not guaranteed)? At first glance, it would seem that the answer is simple - is that the employee must earn extra money and these payments should not be included in the tariffs? But if these types of incentive payments were not included in the tariffs or the amount of per capita payment, then where will the institution get the funds to pay them if the employee has reached the indicators for which these incentive payments are made? But if these payments are established, it is impossible not to pay them.

What wage level should be used in the calculation of piece rates (in the case of piece rate systems)?

What level of wages should be used when calculating the standards for wages from the cost of services rendered (in the CHI system and in the provision of paid services)?

How to form the planned size of the wage fund (with or without taking into account those types of incentive payments that are not guaranteed)?

All this should be clearly regulated - unresolved issues can become the subject of numerous litigations.

The need to revise the salary structure is connected with something else. In accordance with the Decree, the change in incentive systems will include the abolition of permanent payments that are formally classified as incentives, but do not really motivate employees to perform their job duties efficiently and efficiently, with the possibility of reallocating funds to increase employees' salaries and real incentive payments.

Obviously, first of all it concerns probationers. Indeed, now they relate to incentive payments. But what are they stimulating? Unfortunately, no result. Previously, there was a certain reason to stimulate continuous work in state (municipal) healthcare institutions, but now the situation has changed. If the state is interested in competing in the labor market in order to return part of the medical workers who left for commercial medical organizations to other areas, then it is inappropriate to pay them as they have lost their experience (at the level of novice doctors, etc.). In general, to refuse traineeships, obviously, is also not the best option. The most logical is to include internships in the salary (now referred to as the base).

The psychological assessment by medical workers of the adopted wage system should also be taken into account. If we start from the base salary, as it is now, then the workers consider it as the level of payment provided by the state, considering it beggarly, and everything else, they say, they themselves have earned. Therefore, even when sometimes receiving very decent wages, medical workers often consider their wages (understanding it only the base salary) as offensive.

As you can see, the use of the concept of "base salary" is not a very good solution from a number of positions (part-time jobs are paid much lower than work at the main rate; "harmfulness" is paid only according to the base salary, etc.). One of the options is the use (as in St. Petersburg) of the concept of "base unit", which serves as the basis for the formation of a salary.

It is noteworthy that the regulatory documents relating to an effective contract do not set the task of raising the wages of each individual employee to the established level - we are talking about the regional level. Therefore, the wages of employees holding the same positions, not only within different institutions, but even within the same institution, can vary significantly.

In addition, within the framework of the implementation of the measures envisaged during the introduction of an effective contract, a significant convergence of the salaries of junior and secondary medical personnel and a decrease in reasonable differentiation are possible.

In general, in the orientation of an effective contract only on incentive payments (which follows from its definition), we see the main risks associated with the implementation of an effective contract. An effective contract cannot be based solely on incentive payments. Otherwise, we drive ourselves into a "Procrustean bed." It is necessary to use all possible potential options for the introduction of incentive pay systems, including the use of piecework pay systems.

Further. In accordance with the Decree, an increase in the wages of employees in the public sector of the economy must be ensured with the possible attraction for this purpose of at least a third of the funds received through the reorganization of inefficient organizations.

Here one can clearly see the policy of the state to optimize the network of state (municipal) healthcare institutions, which can only be welcomed. However, our country has always been characterized by excesses. There are risks of their manifestation even now. Already at times one hears statements by regional authorities that one third of all the funds needed to raise wages should be provided by reorganizing the institutions themselves and reducing the number of employees. But this is a clear distortion of the phrase of the Presidential Decree. The Decree of the President says that at least a third of the possible savings obtained through the reorganization of inefficient institutions should go to wage increases. And precisely inefficient institutions. Therefore, in order to avoid such excesses, the following is necessary.

Serious work is needed to substantiate the expediency of reorganization. First of all, it will be necessary to develop clear criteria for the concept of "inefficient organization". Moreover, with the obligatory consideration of economic indicators. Paradoxically, at the present time there are no such criteria in healthcare at the federal level (in most cases, there are none at the regional level). More precisely, there are only criteria that serve as the basis for stimulating the heads of institutions, but not for making managerial decisions on changing the head, reorganizing institutions, etc.

Of course, in some cases, the association can reduce irrational administrative and economic costs. But will this alone increase the efficiency of the affiliated institution, will it improve the quality of medical care provided? To what extent will this be a real source of funds for wage increases? Won't the process of mere mechanical merging of two or more health care institutions be more likely to backfire? All such questions must be answered before the reorganization process begins.

The Order states that the basis for increasing the stimulating role of wages will be the construction of end-to-end sectoral systems of indicators for assessing the effectiveness of institutions in the provision of state (municipal) services (performance of work) according to the principle "Russian Federation - subject of the Russian Federation - institution - employee".

In principle, the idea is correct, but, unfortunately, it is not always implemented in practice. Thus, the state is interested in reducing the volume of inpatient care. But this does not mean that the hospital workers themselves need to be stimulated for reducing the volume of inpatient care provided. And the salaries of specialists in diagnostic services, workers involved in medical examinations, etc. cannot be tied to morbidity rates. - detection rates will immediately drop sharply. Therefore, adhering to the cross-cutting principle as a whole, it is necessary to stimulate work taking into account the characteristics of a particular position, a particular employee.

Experts point out that for the successful transition of the public sector to an "effective contract" the main problems have not been resolved: what is considered the result of labor, how to measure the result, by what parameters, etc. “It is desirable to measure the result of work in order to know whether this or that institution, this or that employee is working well. It is difficult to do this, but it is possible ... This is a complex problem that requires painstaking work. As always, we strive to solve everything with a fast-paced campaign. There is a great danger here, which can lead to discrediting the idea of ​​an effective contract, which makes sense," Pavel Kudyukin*(4) believes.

Let's point out another serious risk. There is no guarantee that wage increases will not come at the expense of reduced spending on medicines, equipment, repairs, and so on. Even now, often the financial authorities of the constituent entities of the Russian Federation, pointing to the equipment purchased under modernization programs and the prospects for wage increases, make it clear that it is not planned to allocate any significant funds for equipment and repairs in the near future.

Thus, the implementation of an effective contract involves the solution of many problems, some of which have not yet manifested themselves. These decisions must be balanced and justified.

IN AND. Starodubov,

F.N. Kadyrov,

FGBU "Central Research Institute of Organization and Informatization of the Ministry of Health of the Russian Federation",

Moscow, Russia

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*(1) See page 66 of the Health Manager magazine, N 2, 2013, heading "Health Manager consults" - editor-in-chief N.G. Kurakov.

*(3) Appendix No. 4 to the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018 (Decree of the Government of the Russian Federation of November 26, 2012 N 2190-r "On approval of the Program for the gradual improvement of the wage system in state ( municipal) institutions for 2012-2018").

*(4) Effective state employee. http://www.vz.ru/economy/2012/7/11/588045.html.