An effective contract in healthcare: the pros and cons of the new system. An effective contract in a medical institution

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 on 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 the issues directly related to the remuneration of workers: 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 length of working time 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 labor results 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 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 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 framework of the institutions, there was usually no linkage of the additional payment of the worker to 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, and 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 of 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 cheated - 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 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. So, 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 Decree, "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 norms also include the achievement of a certain minimum level of quality 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 are 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 accepted system of remuneration 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 option is to use (as in St. Petersburg) 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, as part of the implementation of the measures envisaged by 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 of 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 sometimes one hears the statements of the regional authorities that a third of all the funds needed to raise wages should be provided by reorganizing the institutions themselves, 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 management 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 effectiveness of the activities 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? Wouldn'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 works 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 p. 66 of the Health Manager magazine, N 2, 2013, heading "Health Manager consults" - editor-in-chief N.G. Kurakov.

*(3) Annex 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.

December 16 at the Palace of Trade Unions on the square. Labor, 4 hosted a seminar organized by Terkom on effective contracting in healthcare.

Read F.N. Kadyrov (Deputy Director for Economic Affairs of the Federal State Budgetary Institution "Central Research Institute for the Organization and Informatization of Healthcare" of the Ministry of Health of the Russian Federation, Doctor of Economics, Professor, Honored Economist of the Russian Federation) clearly and in detail set out the regulations and facts that are associated with the transition to an "effective contract ", its true purpose, the nuances for leaders in the design of this transition, forecasts for the period up to 2018 regarding the implementation of Presidential Decree 597.
After listening to the lecture, there was a strong feeling that it was read not for employees, but for managers, since all the stages of transferring subordinates to a new work format are listed and provided "on a silver platter", methods of "painless" transfer using skillful manipulation of employees and silences, notification forms and tactics of the personnel department.
On the other hand, you need to know the enemy by sight. And there are a number of ways for the employee and the team by which one can not prevent the transition - it will happen sooner or later, but delay it, gain time, in response to new demands from the employer, knock out new rights, prescribe subtleties in the collective agreement, follow the development additional agreements to labor contracts.
So, the report on the lecture (with the conclusions of the listener).

What is an "effective contract"?

The term "effective contract" (EC) implies:
- in the narrow sense - an employment contract.
- in a broad sense - a set of measures aimed at improving the quality and accessibility of medical care.

An effective contract is primarily aimed at SOLVING THE PERSONNEL ISSUE. The promised increase in wages is only a method of solving it.

At the same time, it is during this period (2013-2014) that the trade union committee and employees have the opportunity to demand payments, since the situation in the legislative sphere at the level of institutions is rather blurred. In almost any situation where an employee is deprived of payments, if an audit is initiated, the issue will be resolved in favor of the employee. In addition, the employer is required to meet the wage ratio indicator in his institution according to the road map.

* What to do if an employee is deprived of incentive payments?

Contact the union!

A representative of a trade union organization, both under the conditions of an "effective contract", and in conditions where the transition to it has not yet taken place, must take part in the work of the commission for calculating incentive payments - it exists in every institution.
It also includes: chief accountant, head of the economic department, chief medical officer. The decision of the commission is made signed by the chief physician.
In the event that this commission decides to deprive the employee of the incentive payment for any reason, the consent of the representative of the trade union organization is asked.
In such a situation, he must express disagreement with the deprivation of the employee of the incentive payment. And if he fails to convince the employer, then the mechanism is as follows:
The chairman of the trade union organization writes a complaint against the employer (chief physician) on the fact of depriving the employee of payments to the following authorities: the President of the Russian Federation, the Plenipotentiary of the President of the Russian Federation in the region / city, the Ministry of Health of the Russian Federation, the Ministry of Labor, the State Labor Inspectorate, the prosecutor's office, the governor / mayor, the Health Committee, Turkom , Rayzdrav.
The complaint indicates to which authorities copies of the complaint were sent.
The expected result is:
payment of funds in full, since the manager will be called to higher authorities (Gorzdrav, Rayzdrav), and in order to prevent further proceedings from above, he will be ordered to resolve the issue in a manner favorable to the employee.

What criteria for evaluating labor efficiency can be applied to employees?

The criteria, indicators and frequency of assessing the performance of employees are established ONLY by the institution on the basis of methodological recommendations and orders. In other words, the employer can introduce any criteria for assessing labor efficiency for the employee - against this background, the responsibility of the trade union team and workers who are not members of the trade union should increase. It must be emphasized - THE TEAM - since the chairman of the trade union organization is unlikely to cope with such a volume of work. Any worker, even if he is not a member of a trade union, has the right to support and protection of his rights by the trade union organization.

Can an employee be fined under an effective contract?

According to the Labor Code, the use of disciplinary measures is strictly prohibited, except for the penalties provided for by the Code itself, federal laws, charters and regulations on discipline. An employee cannot be forced to work without days off or deprived of vacation. You can't fine an employee.
When an employee commits a disciplinary offense, the employer (Article 192 of the Labor Code of the Russian Federation) has the right to: make an oral or written remark to the employee, announce a reprimand, dismiss the employee. In addition, the procedure for applying disciplinary sanctions is clearly spelled out in Art. 193 of the Labor Code of the Russian Federation algorithm.
In the context of incentive payments, it may not be the imposition of a fine, but the non-accrual of a premium, i.e. if employees fail to fulfill a number of criteria, the bonus will not be partially or completely calculated.
The additional agreement should clearly spell out all the incentive payments due to the employee, the conditions for their non-accrual and the criteria by which they are accrued, as well as the amounts. The employer in the "amount" column may not give specific numbers or points and refer to the collective agreement and the regulation on remuneration, the provision on the calculation of incentive payments.
If you have been withdrawn a certain amount (say, 1000 rubles for non-compliance with the dress code), you have the right to go to court, where the employer will have to explain on what basis this particular amount was withdrawn. Therefore, if such subtleties are not spelled out in local regulations, the court will rule in your favor.

An effective contract as an employment contract.

The concept of an effective contract does not yet exist in the Labor Code - the concept of "employment contract" is used.
In order to improve the quality of medical care, and, accordingly, tighten the demand from medical workers, the government recommends REFINE the employment contract in the form of an effective contract.
That. An effective contract is an employment contract that specifies job responsibilities, wage conditions, performance evaluation criteria for assigning incentive payments, as well as measures of social support for employees.
If earlier it was enough for an employee to perform his job duties without focusing on specific indicators, then when switching to an EC, work will be characterized not only by the performance of a function, but also by a number of specific indicators.
As for existing employment contracts, your management has no right to terminate them and conclude new ones.
In addition, according to the correct algorithm for the transition to EC, the conclusion of additional agreements to employment contracts is one of the final stages.

IMPORTANT! Stages of transition to an “effective contract” or what an ordinary worker and members of a trade union organization need to know.

1. We do not sign any contracts and additional agreements immediately!
By law, you must be given a written notice of a change in the terms of the employment contract determined by the parties (transfer to a new wage system and the need to conclude additional agreements to the EXISTING EMPLOYMENT CONTRACT) no later than 2 months before the transfer.
Amendments to the employment contract in this situation are carried out on the basis of Article 74 of the Labor Code of the Russian Federation (due to organizational or technological changes in working conditions).
In no case is it unacceptable to renegotiate an employment contract (termination of an existing contract and conclusion of a new contract) - since this means dismissal with subsequent employment. Perhaps this is a tactical move in order to eliminate an objectionable employee - they simply may not accept you again.
2. So, a general meeting was held, at which you are informed about the need to switch to a new wage system - an effective contract with the need to conclude additional agreements.
3. Then, one by one, the employees are called to the personnel department, where they are orally notified of the need to sign an additional agreement to the employment contract. Arguments of haste can be different - "it is beneficial for you, everything is clearly spelled out there", "otherwise you will not receive bonuses", "everyone will have to sign anyway", etc.
Don't worry - bonuses will be paid to you, because it is unprofitable for the employer to reduce the average level of wages - his bonus also depends on this. And if they don’t risk not paying, we read the paragraph * What to do if the employee is deprived of incentive payments?
And there is only one reason - for an early or timely transfer, managers are given a bonus.
There are those who will sign right away. To the joy and relief of personnel officers and superiors.
4. Is the employee required to sign an additional agreement immediately?
No. Firstly, you are required to give TWO MONTHS IN WRITTEN NOTIFICATION of changes in the terms of the employment contract determined by the parties.
According to the article of the Labor Code of the Russian Federation, you have 2 months to think. If you do not show your disagreement in any way, after 2 months you will still be transferred to EC.
If you write “do not agree” on the notice or in the application addressed to the employer, 2 months after signing the notice, you are required to provide a vacant position that matches your qualifications or less paid *
* it is important that working conditions should not worsen the position of the employee compared to the conditions prescribed in the collective agreement, and the vacancy must be provided in the same locality, for example, an employee of a district hospital in the city should not move to a branch in the village, unless this is provided for by the collective contract.
If there is none or in case of refusal in accordance with article 77, part 1 of the Labor Code of the Russian Federation, you can be fired.

Why wait 2 months then?

In a situation where the employer first of all requires the employee to sign an additional agreement, without foreseeing changes in the collective agreement, the provision on incentive payments, we can talk about a violation of the transfer algorithm to the EC.
The first stage of the transition is the development of a collective agreement with the trade union committee, provisions on incentives (since the additional agreement will contain incentive payments, most likely with reference to the collective agreement and the internal regulation on incentives).
Only after that you can make changes to the employment contract with the employee.
Speaking of the collective agreement, its standard form is laid out in our documents, but in each institution the trade union committee can defend private details, since we are talking about an agreement, a contract - and this implies negotiations, concessions and agreements from BOTH PARTIES. The employer will not miss the opportunity to expand and deepen the range of your job responsibilities - so do not miss the opportunity to receive new rights and additional payments.
In addition, while you are working under a valid employment contract and the provision for accrual of incentives, bonuses should be paid to you on an equal basis with other employees. To the threats of the personnel officer (“since you have not signed an additional agreement, you are not entitled to a bonus”), immediately ask for a written justification for such a statement.

Are employees who do not perform medical services included in the list of employees covered by the Decree of the President of the Russian Federation? Should their salaries be raised?

According to regulatory documents, a statistician, an accountant, a personnel officer of a healthcare facility are not included in the list of groups of workers who should receive a salary increase, however, this is not prohibited - in the case when the target level is reached for the categories of workers indicated in the road map. This issue is up to the employer.
The same applies to employees of children's institutions - raising their salaries is the right of the institution.
It is also desirable to reflect these points in the collective agreement.

How fast will wage increases be?
According to the roadmap, the maximum increase in wages is planned for 2017.
However, until 2015, the pace will be low. First of all, this is due to the calculation of tariffs in accordance with Federal Law 354 of November 30, 2011 "On the size and procedure for calculating the insurance premium tariff."

Why hasn't my payroll increased?

The worker says:
- if, according to Presidential Decree No. 597 and the road map, the salary of a doctor in 2013 should be 129.7% of the average for the region (for doctors in St. Petersburg, the average salary should be about 47 thousand), then working for one and a half two bets I will earn one and a half to two times more - 60-90 thousand.
However, this does not happen. Why?

The assessment of the level of wages is currently carried out for one individual.

How is the average wage calculated?
Based on the order of Rosstat No. 574 dated October 30, 2012, the calculation of the average salary of employees is carried out by dividing the wage fund by the number of INDIVIDUALS for these categories of employees (for example, heads, doctors, nurses, nurses are counted separately). Thus, given the high percentage of internal combination in medical institutions, according to the monitoring carried out in accordance with Order 574, the average salary turns out to be higher than the average salary per rate.
And, accordingly, basically, the target indicators are considered achieved - there is no need to pay extra to employees! And the indicators are met, and the rates are covered, and the head physician receives incentive payments for achieving the set indicators. Only the employee is at a loss.
Not all employees will be able to receive the amounts specified in the roadmap. Salary will depend on qualifications, quantitative and qualitative indicators of work. PART OF THE EMPLOYEES WILL NOT RECEIVE THE SALARY IN THE AMOUNT PROVISED IN THE DECREE OF THE PRESIDENT. Thus, STIMULATION is achieved.

What to do in such a situation?
It is clear that from 2013-2014, especially in connection with the transition to an efficient contract, the employer's incentive payments will depend on the achievement of target indicators of the average salary for the institution.
In such a situation, he will be forced to "stretch" the wages of his employees.
And now let's think about what is more profitable - to work like a normal person, at a rate, go home on time or to an external part-time job and receive a base salary of 17 thousand plus incentives up to 47 thousand, or work for two rates in one institution, earn a salary of 34 thousand and get incentives in the amount of 13 thousand?
Therefore, many workers see a way out in the "Italian strikes" - work strictly according to the labor code, with the performance of job duties, recruitment standards for no more than a rate, in compliance with the admission regulations.

The concept of an effective contract is enshrined in the Decree of the Government of the Russian Federation of November 26, 2012 No. 2190-r, which approved the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018. It is an employment contract, which describes in detail the scheme for calculating the amount of remuneration, depending on its effectiveness. All public sector employers were required to conclude such contracts with employees. Health care workers are no exception.

Tasks and criteria for an effective contract in healthcare

The introduction of a system of effective contracts in the healthcare system pursues the following tasks:

increasing the prestige of work in budgetary medical institutions;
maintaining human resources;
bringing the amount of wages in line with the quality and volume of services provided.

From these tasks, it follows that the main goal of the new type of contracts is to motivate medical workers to achieve better results in their professional activities, as well as to comprehensively improve the quality of services. For this, special criteria for evaluating the effectiveness of work are introduced, which are fixed in the employment contract. When determining them, it is recommended to rely on the Order of the Ministry of Health of the Russian Federation No. 421 of 06/28/2013 and the Order of the Ministry of Labor of the Russian Federation No. 287 of 07/01/2013.

An effective contract in healthcare: performance evaluation criteria

Examples of criteria for assessing the quality of work of doctors can be the absence of:

medical errors and deaths;
errors when working with documentation, violations of workflow and other procedures;
justified claims to the quality of work;
violations related to the performance of official duties and instructions.

As for nurses and other paramedical personnel, their work should not include:

violations in reporting, storage and accounting of drugs;
violations in the order of care and observation of patients;
complaints from doctors, etc.

The list of criteria is far from complete, it may include various statistical indicators, such as the number of patients admitted, the percentage of vaccinated, and so on.

An example of an effective contract in healthcare

In the new contract, in addition to the scheme for assessing the quality of work, the procedure for various payments should be described. Usually, payment in medical institutions consists of a salary, incentive payments, compensations and bonuses. The amount of compensation cannot be lower than that established in the labor legislation. They can be charged for combining positions, difficult and harmful working conditions, night work, for replacing an absent employee, etc.

Incentive payments, according to the Letter of the Ministry of Health No. 16-3/10/2-6752 of 09/04/2014, are paid for:

high labor intensity;
the quality of the services provided;
work experience and length of service;
performance results for a specific period.

All conditions for calculating additional payments must be agreed in relation to each employee.

You can download a sample of an effective contract in healthcare below.

Transition to efficient contracts in healthcare

An employee who gets a job signs an agreement drawn up according to the new rules. With those who worked in the organization before, an additional agreement is concluded, in which all innovations are made. At the same time, the employer is obliged to notify employees of the planned changes at least two months before they are introduced. If an employee refuses to sign an additional agreement, then the employment contract with him can be terminated, in accordance with paragraph 7 article 77 of the Labor Code of the Russian Federation. It is recommended to make the transition in accordance with the following algorithm:

The head issues an order on the implementation of new contracts.
A working group is being created, which includes representatives of the trade union, workers, and managers.
Efficiency criteria are being developed.
Model employment contracts are drawn up for new employees and supplementary agreements for existing employees.
Employees are notified of upcoming changes.
Amendments are being made to the Regulation on remuneration (on the introduction of incentive payments depending on the results of work), employees are familiarized with the document for signature.
Changes are made to job descriptions, employees get acquainted with them under the signature.

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 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

Fixed wages, as a rule, do not encourage employees to perform their duties at a high level. Indeed, why work hard when you can meet the minimum requirements and get the same money?

Until 2012, clearly defined wages for a specific specialty were prescribed in employment contracts, and this approach formed negative labor market trends:

outflow of young specialists and valuable personnel;
low quality of medical care to the population (as a result of lack of motivation to perform their work at a high level);
the main income of physicians is unofficial paid services, which means: patient dissatisfaction, insufficient budget filling and underfunding of the industry as a whole.

According to the Decree of the Government of the Russian Federation of November 26, 2012 No. 2190-r, the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018 was approved. The key reform of the program is to increase the effectiveness of the contract form of interaction between employers and employees.

An effective contract is a special form of an employment contract between an employer and an employee with prescribed job responsibilities for a particular employee (and not just a representative of a certain specialty) and criteria for evaluating the effectiveness of the work done. From these indicators, wages are formed, which include incentive bonuses.

The Appendix of the Program indicates a sample of an effective contract in healthcare, the mandatory conclusion of which is planned to be introduced in all state institutions by 2018. Methodological recommendations for the introduction of an effective contract in healthcare have also been developed.

Will an efficient contract be efficient?

In the article "Effective contract in healthcare", Doctor of Economics F.N. Kadyrov reports that the transition to an effective contract in municipal institutions will clearly determine the dependence of the wages of medical workers on the quantity and quality of work performed. Now, when concluding an employment contract, each employee will clearly understand the scope of his duties and the potential amount of additional payments that he can receive by performing his work at a high level.

You can see an example of an effective contract in healthcare.

Based on the provision on an effective contract in healthcare, we can draw conclusions about the following advantages of the innovation:

Incentive for staff. Overfulfilled the planned amount of work - received a solid bonus.
Improving the quality of medical care. Employees interested in salary increments perform their duties more carefully. As a result, patients receive higher level medical services.
Growth in the average wage of healthcare workers.

In institutions that have switched to an efficient contract, there is already a positive trend in the growth of doctors' salaries. Thus, Sada Nazimovna Bagirova, Head of the Human Resources Department of MBU DGB No. 5 of Yekaterinburg, confirms: “... in addition to the guaranteed payment (salary, bonuses for the position, length of service, category, harmfulness), doctors, depending on their specialization, receive incentive payments from 20 to 28 thousand rubles.

True, not everything is so smooth

In general, the idea of an effective contract contains many positive aspects. However, in practice there are some problems associated with its implementation. The new wage conditions raise many questions among employees of state medical institutions about the size of wages.

The current labor assessment systems have many significant shortcomings. Thus, the initial idea was to create performance criteria for each position (for example, a points system). Each specialist receives an assessment of the work done in points, which are summed up, multiplied by a constant, and the result is paid to the employee. However, this method requires the creation of a new department in institutions that would deal exclusively with scoring, since municipal clinics can have several hundred employees, which greatly complicates and slows down the scoring process.

Another significant problem is insufficient funding for the healthcare sector. According to the Accounts Chamber of the Russian Federation, in 2014 the deficit amounted to 55.3 billion rubles. The wage fund is simply not designed for the fact that all employees will fulfill the plan by 100%. Therefore, the management of medical institutions often faces a situation where the plan is fulfilled, but there is no money to pay bonuses. So it is necessary to initially indicate a small coefficient for incentive payments in employment contracts.

What should be expected?

In accordance with the Decree of the President of the Russian Federation of May 7, 2012 No. 597 "On measures for the implementation of state social policy", by 2018 it is planned to increase the average salary of doctors to 200% of the average salary in a particular region. Therefore, it remains to be hoped that the financing of the healthcare sector will improve. In the meantime, all municipal medical institutions need to switch to an effective contract system.

The form of an effective contract in healthcare, as an improved type of employment contract, can change the current state of affairs for the better. Its implementation creates a significant incentive for healthcare workers. As for the shortcomings of this system, active work is currently underway to simplify and improve it. In the article "New effective approaches to remuneration of medical workers" (Borisova E.A., Savina N.V., Lutskan I.P., Timofeev L.F.), the authors propose to solve the problem of the complexity of regular assessment of the work of employees using computer programs.

We invite you to take part in the International Conference for Private Clinics , where you will get the tools to create a positive image of your clinic, which will increase the demand for medical services and increase profits. Take the first step towards the development of your clinic.

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