Modernisation and Governance: the case of Italian Health Care organisations Cristina Masella Politecnico di Milano Dipartimento di Ingegneria Gestionale Piazza Leonardo da Vinci, 32, 20133 Milano e-mail: cristina.masella@polimi.it Nadia Piraino Politecnico di Milano Dipartimento di Ingegneria Gestionale Piazza Leonardo da Vinci, 32, 20133 Milano e-mail: nadia.piraino@polimi.it 1. Introduction Since 1992 the health sector in Italy has undergone significant reform processes (Legislative Decree no. 502/92 and no. 517/93) which have been based on the British “internal market” model. These changes have led to the definition of a new national regulation reference system for the various regions whose fundamental points are the starting up of a “managerialism” process and an innovative funding mechanism of the services (the Diagnostic Related Group, DRG, system) with an increase in the participation of the costs by the patients. Subsequently, with law no. 419/98, which was put into practice as legislative decree no. 229/99, the following have taken place: • the regionalisation and “managerialism” process of the hospital structures has been completed; • the integration of social and health services have been more precisely regulated; • the regulation of the contracts between commissioner and provider of health services has been extended; • the working activities of the medical staff have been more rigorously regulated both within and outside the NHS structures. With the modification of title V of the Constitution (constitutional law no. 3/01), the health service has fallen under the exclusive legislative power of the Regions (devolution process). The State determines, and then foresees to the financing of “… the essential levels of the services concerning the civil and social rights that should be guaranteed throughout the entire national territory” (art. 117, comma 2 letter m), and control and monitoring mechanisms can be carried out of the activities conducted by the local government agencies. From the economic point of view, the changes and tendencies that have modified the institutional policy framework of the Italian health system have pointed out the existence of some typical quasi-market components (Bartlett and Le Grand, 1993): there is a separation between the demand and supply functions of the services and, as a consequence, the suppliers are encouraged to compete with each other to satisfy the demand (increase in competitiveness) (Bosi, 2006). These factors have led to the introduction of new organisational forms, which have the aim of improving efficiency in the supply of the services, thus contributing to the process that was started in the eighties of changing and modernising the public sector, whose theoretical lines were defined according to the New Public Management (NPM) (Hood, 1991 and 1995). It is possible to identify a common denominator of these changes; there are in fact three characteristics that are usually associated to the reforms that have involved the welfare system of Western countries (Kickert, 2001): - the introduction of competitive mechanisms onto the market, - customer orientation, - the introduction of business management techniques (product orientation, costs orientation, output budgeting, and performance indicators and contract management). To put it very concisely, public management has started up a managing change process at an “inter-organisational” level (Metcalfe, 1993), introducing some of the instruments of the private sector, such as, for example, performance measurement, customer and bottom line orientation, incentive schemes that seem to be coherent with 2 some of the phenomena that were started up in the same years (privatisation, hollow state, externalisation of the functions, reduction of the administrative constraints, etc) (Hirst, 2000; Brudney et al. 2000; Lane, 2000; Lynn, 1998; Minogue et al. 1998; Pollitt and Bouckaert, 2000). In this context, Osborne and Gaebler (1992) introduced the concept of “reinvent government”, distinguishing “steering” (policy decisions), of which modern state needs more, from “rowing” (services delivery), of which modern state needs less (Van Kersbergen and Van Waarden, 2004). 2. Hospitals: a continuously evolving organisation In the light of these changes, hospitals have evolved from being supply-driven organizations to demand-driven institutions. Until quite recently, the management bodies of the health organizations were only involved in managing the structures and infrastructures, the departments and sectors, on the basis of tendentially uniform norms and regulations, while now attention is concentrated above all on the health service demands made by the patients and on the necessities of the other stakeholders (Eeckloo et al. 2004). It is in fact the presence of a multiplicity of stakeholders (who inevitably influence the governance and decisional process) which makes the health system particularly complex. It is increasingly more difficult to define the boundaries of the organisations, which are characterised by a rather open structure and solicited by continuous interactions with the environment in which they work (McKee and Healy 2002). Studying the health (and hospital) structures therefore means analysing the different policy strategies that are influenced by external and internal pressures towards change. On the other hand, numerous studies have shown how, in spite of the multiplicity of solicitations in favour of change, the health structures find it difficult to reinvent a new organisational structure and in fact demonstrate a resistance to radical changes (see, for example, McKee and Healy, 2002; McNulty and Ferlie, 2004). In the case of public agencies as the hospitals, the area in which they must work seems to be a grey zone somewhere between the public and private sector: they are in fact financed by the local governments which supplies both clinical and economic objectives, but at the same time they “compete” with private companies, thus ending up in a situation in which they are obliged to emulate the styles and instruments of the private sector but without being able to forget their origin and nature. Kickert (2001) defines this type of company as being a hybrid or as a quasi-autonomous executive structure. The situation in Italy in reality appears to be very different from region to region and, as a consequence, the move towards change has not been promoted everywhere and where it has taken place, it has not occurred in a homogeneous manner. The introduction of quasi-markets has in fact come into contrast with both theoretical and institutional questions (Le Grand, 2003). From the conceptual point of view, “health” goods are considered “social goods” and the separation of the supply and demand functions of the health services has been seen by the policy-makers as a threat rather than an incentive towards efficiency and in this way a heterogeneous situation has been created throughout the national territory, so much so as that hostility has been created towards the quasi-markets. There are three reasons for this failure (France, Taroni and Donatini, 2005): 3 1. the normative has left the regions to decide the level of separation between the supply and demand functions: the result has been that only the Lombardy Region has reorganised the regional health service according to the quasi-market logic, while both functions work side by side in the rest of the country; 2. the regional financing mechanisms differ and the Region continues to play a dominant role, above all in the southern regions; 3. the normative has foreseen that the accrediting procedures falls under the regional competence, consequently the Regions (except Lombardy) have limited access to private suppliers. In this context, some authors note that the 1999 reform involves a revision of the 1992 market-based approach, with shift form managed competition to managed cooperation (France 2001; Light 1997). 3. The objectives The evolutions that have involved (and continue to involve) the health system from an overall point of view and the consequent changes in the role of the health structure has led to increased research activity in different environments: technology assessment, performance measurement, clinical governance, networks of public interest, etc. This present work is focused on the study of the governance structures that have been adopted by the Italian health organizations. The differences that exist between the for-profit and the not-for-profit sectors, both in terms of missions of the organisations and of the type of relationships (emphasis in fact moves from the shareholders in the private companies to the stakeholders in the public or not-for-profit sector), do not allow the corporate governance principles (intended as management and control of the company) to be transferred from the private to the public (or not-for-profit ) sector (Eeckloo et al. 2004; Newhouse, 1970). In this context, it seemed interesting to investigate the hospital governance models that have been adopted by the various health organizations throughout Italy in order to be able to respond in a sufficient way to the changes in the context in which they work. The objective was therefore that of defining typical configurations or perhaps even individual trends and common features in relation to the relevant characteristics of the examined structures. In brief, the research consists in: 1. identifying the relevant variables for the definition of hospital governance; 2. identifying any typical configurations; 3. analysing the diffusion of the different models throughout Italy. 4. Theoretical framework The research focuses on the analysis of how a special category of quasiautonomous executive agencies – as the hospitals – have fitted context evolution. In particular, the objective is not to study the governing bodies of the hospitals (defined by law) but it focuses on the impact of the regional system on the governance structure and on the management-style of the healthcare organizations. 4 The term governance is really hard to define without ambiguity, because reforms in public sector have been the subject of a number of disciplines that gave to the term different meanings, different perspectives and different usages. The concept of governance that we analyze in that context is in the middle between public governance (external perspective) and new public management (internal perspective). The aim, in fact, is to investigate the coordination arrangements and managerial tools used not just “inside” the organization but also “outside”. According with Lynn et al. (2000; 2004), public sector governance is: “regime of law, rules, judicial decisions and administrative practices that constrain, prescribe and enable the provision of publicly supported goods and services” through formal and informal relationships with agents in the public and private sector (Lynn, Heinrich and Hill 2000, 2001; Hill and Lynn 2004). In particular, the authors argue that public governance is the outcome of a dynamic process that involve different level of collective actions (Hill and Lynn 2004): 1. between (a) citizen preferences and interests expressed politically and (b) public choice expressed in enacted legislation or executive policies; 2. between (b) public choice and (c) formal structures and processes of public agencies; 3. between (c) the structures of formal authority and (d) discretionary organization, management, and administration; 4. between (d) discretionary organization, management, and administration and (e) core technologies, primary work, and service transactions overseen by public agencies; 5. between (e) primary work and (f) consequences, outcomes, outputs, or results; 6. between (f) consequences, outcomes, outputs, or results and (g) stakeholder assessments of agency or program performance; 7. and between (g) stakeholder assessments and (a) public interests and preferences. Following the logic of governance suggested by the authors, the present study takes place between level (c)-(d) and (d)-(e). To be more precise, it analyses: • external governance, related to relationship between local government and general management; • internal governance, related to the strategies, tools and relationships that characterize the organization and the involvement of the internal actors in the decision making process. 5 Governance structures of quasi-autonomous agencies are affected by a myriad of relationships: public managers, in fact, are involved in a huge number of relationship structures to develop decision making process, implementing strategies and policies and identifying priorities in their strategic agenda. These set of relationships involve managers and politicians, but also employees, other managers and other organizations (Feldman and Khademian 2002). Again, Borgonovi (2002) argues that, in a logic of governance, the ability of managers to problem solving not depends on formal power and rules, but on the ability to involve different actors in decision making process, using incentive schemes to achieve the objective. 4.1 External governance Despite different approaches and definitions of public governance, literatures review highlighted some common emerging problems: accountability, governability, and legitimacy (see for instance, Rhodes 1996; Frederickson 2004; Van Kersbergen and Van Waarden 2004). Accountability is a central issue of the governance logic: with devolution of the functions from central government to quasi-autonomous agencies (hollow state phenomena), new accountability arrangements become key factors to checks and balances on power: systems of checks and balances to control the exercise of the power of the quasi-autonomous agencies have gradually developed and public managers became accountable (Van Kersbergen and Van Waarden 2004). Moreover, accountability is deeply linked to governability. Governability, defined as the ability to solve urgent societal problems, often required a certain centralization and concentration of political power. Hence, there is a trade-off between control system and degree of autonomy of public managers: an over-control could narrow the strategic space of the managers (and, consequently, could limit the governability) and, to the contrary, a not enough control could encourage opportunistic behaviours and increase risk of arbitrariness and/or corruption. Regarding the third factor, in a government logic legitimacy of decisional authority is a result of formal power, wielded though rules and procedures outlined ex ante; in a governance logic, instead, legitimacy is a result of ability of the public managers to create consensus on decisions of public interest, in a participative view of decision making process (Borgonovi 2002). That means in this concept of governance, linked to coordination mechanism among different actors, participation and involvement become distinctive characteristics of legitimacy, compared with traditional government approach. In this point of view, legitimacy depends on form of governance emerging at regional level (quasi-markets, quasi-network, quasi-hierarchy). Adapting Lynn et al. model, the relevant aspects regarding external governance are: • analysis of contextual factors, in terms of: o emerging forms of governance at healthcare regional system level • analysis of relationship between central (regional) government and general manager of the public hospital, in terms of o level of external authority o accountability line/degree of external control 6 Depending on the level of autonomy and the degree of external control, from an external perspective the governance style is characterize by a governance vs government approach. 4.2 Internal governance From an internal point of view, given the nature of healthcare organizations (high degree of professionalism, fragmented know-how, high interrelations among different organizational units) decisional making process is very complex (Mintzberg 1993). Decisional actor, in fact, is a “composite decisional actor” (Achard, Cicchetti e Profili 2000; Cicchetti 2004) and high degree of power “dilution” could encourage opportunistic practises in the use of information (Achard, Castello e Profili 2000). In particular, alongside to administrative structure, there are the professional groups which constituting the “operating core” of the organization, with autonomy from direct line of administrative control (Mintzberg 1993). This organizational model highlights a particular form of “custodial management” (Ackroyd et al. 1989), most developed in the case of the hospitals, where a system of “producers’ cooperative” (Klein 1989) emerged, given the autonomy of the professionals on decision about resource allocation (Ackroyd et al. 2007). Also Kickert (2001) notes the high degree of autonomy that characterize professional organizations, where professionals play a central role in decision process (standard examples are hospitals, universities, and research institutes). The author claims that “in professional organizations, professional priorities usually trump financial or administrative considerations. Because of their special expertise, scientific researchers are given a large degree of autonomy. Public prosecutors vigilantly defend their independence from politics, and public works used to be considered a state within the state. Professional organizations appear to need more businesslike management methods and techniques”. In this context, transparency of information (for professionals) is a crucial aspect in order to take decision consistent with the vision of the agency and governability (intended as stability of the general management) is, in turn, decisive for a long term vision. From an “internal” point of view, legitimacy issues has been investigated considering the degree of involvement of physicians in decision making process, related to particular decisional areas. In conclusion, distinct features of internal governance are related to: • stability of the management • transparency of information • involvement of physicians in decision making process, depicting a participative vs a hierarchical style of management. In short, considering an hospital-centric perspective of analysis, the relevant variables identify in order to investigate “hospital governance configurations” are (Figure 1): • from an external point of view (where emerging forms of governance at healthcare regional system level is a context factor) 1. level of external authority 7 • 2. accountability line/degree of external control from an internal point of view 3. stability of the management 4. transparency of information 5. involvement of physicians in decision making process. Figure 1 – Research framework schema Regional Healthcare System regional government External perspective Healthcare organization Governance vs Government General Management Internal perspective Participative vs hierarchical Physicians Though this model is extremely simplified, it meet the objective of this preliminary study to identify any typical configuration of governance structures of Italian health care organizations. 8 5. Research approach The research aims at characterize governance structures of Italian health care organizations and at analyse the degree of dissemination of different governance models. In order to achieve these research objectives, the survey methodological approach was chosen (Yin 1994). It is an explanatory research in order to carry out a preliminary investigation in this field and to identify some governance-configurations: then, findings are contextualized with the emerging forms of governance at regional level. The survey was conducted at a national level (July 2006) and it involved the entire population of structures operating within the Italian NHS, that is, the Local Health Authorities (ASL) and hospitals under direct management, hospital organisations (AO) (including teaching hospital (AOU)), public and no profit Scientific Institute for Research, Hospitalization and Health Care (IRCCS) and religious hospitals. In September a recall has carried out in order to increase the number of respondents. The questionnaire, prepared in such a way as to be able to reveal and measure the five variables identified in the framework, was given to all the general managers (DG) (or similar figures) in the health structures. A total number of 622 questionnaires was sent and response rate was about 11% (Tables 1 and 2). Although the number of returned questionnaires is low, whatever it allows us to do some discussions about governance structures, resulting from data analysis (even if it is not a comprehensive result). Tables 2 shows an heterogeneous context of the response rate at regional level: in particular, most of the returned questionnaires came from northern Regions, while Centre Italy is almost not represented. A reason of these low response rates could be the historical period, characterized by political elections. In April, in fact, there were Regional elections: in particular in Calabria, Puglia, Sardinia, Lazio and Piedmont there was an handing over from rightwing to left-wing, while right-wing was confirmed in Lombardy and Sicily and leftwing was confirmed in Campania, Basilicata and Liguria. Given the influence of political context on the agency’s role as provider of goods and services and on the governance structures, it could be argue that in some Regions political changes raised a period of transitions for healthcare organizations and it was difficult to be involved in the research. In order to compare different regional contexts, we have considered only the Regions with a response rate higher then 20%1 (Piedmont, Lombardy, Emilia Romagna, Veneto and Provincia Autonoma di Bolzano). 1 Aosta Valley was not included within comparative analysis because the number of respondents is statistically not relevant (just one hospital). 9 Tables 1 – Population of Italian healthcare organizations Regions Piedmont Aosta Valley Lombardy Bolzano Trento Veneto Friuli Venezia Giulia Liguria Emilia-Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicily Sardinia totale ASL 22 1 15 4 1 22 6 7 11 12 4 1 12 6 1 13 12 5 11 9 8 Hospital under ASL direct management 24 1 1 7 10 23 12 10 11 35 9 30 52 22 6 51 27 7 32 49 29 448 Hospitals IRCCS policlinic of which teaching hospital total of which no profit total Research institute Religious Hospitals TOTAL 7 2 2 2 28 17 12 5 2 3 3 5 4 2 2 5 1 2 3 1 3 1 0 1 0 2 3 7 0 4 1 1 5 3 1 0 1 47 0 26 7 2 2 4 17 1 94 1 1 4 1 3 4 8 2 1 1 2 1 9 2 2 8 2 2 23 35 1 51 7 14 34 18 18 17 43 11 35 67 22 8 58 36 9 37 68 33 622 10 Table 2 – Response rate Returned questionnaires Regions ASL Hospital under ASL direct management Piedmont Valle d'Aosta Lombardy Bolzano Trento Veneto Friuli Venezia Giulia Liguria Emilia-Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicily 5 1 -2 1 8 1 6 1 1 2 2 8 1 6 --1 -1 1 2 1 1 2 1 6 --1 -1 1 2 2 1 2 1 Sardinia -- total 34 AO policlinic IRCCS Research institutions Religious hospital total of which AOU total Of which no profit 1 0 0 0 3 1 --- --- --- --- --- -- -- -- -- -- 1 1 6 1 1 1 5 --1 -- 1 0 4 --1 -- 4 1 1 TOTAL Response rate(%) 7 1 11 2 2 9 2 1 11 --2 -1 1 6 3 1 4 3 20,00% 100,00% 21,57% 28,57% 14,29% 26,47% 11,11% 5,56% 64,71% --5,71% -4,55% 12,50% 10,34% 8,33% 11,11% 10,81% 4,41% 2 2 0 0 -- -- -- -- -- -- -- -- -- -- 38 24 7 0 4 2 0 1 67 10,77% 11 6. Findings 6.1 Descriptive analysis Before the governance structures were identified using a cluster analysis, a descriptive analysis has been carried out in order to examine single variables and explore differences among the regions. VAR 1. The degree of external authority The general managers of the healthcare organisation were asked to indicate the degree of autonomy from the region, as far as some decisional aspects were concerned: a) Setting targets for hospital specific health outcomes; b) Strategic planning; c) Management; d) Procurement; e) Capital; f) Human Resources. In particular, the first two points refer to strategic management while the others refer to operative planning. The question foresaw four possible answers according to the following Likert scale: No autonomy, Limited autonomy; Elevated autonomy and Full autonomy. Table 3 shows the frequencies of the answers. It is interesting to note how, in each investigated area (with the exception of procurement and management), the percentages of the structures that have no or low autonomy are high (above 50%), and for the management of the capital (investments and disinvestments) the percentage is even higher than 77% (cumulative percentage). Subsequent to the entrepreneurial NHS process, there are in reality percentages that are much higher in correspondence to a high or full autonomy. This datum, which is relative to the degree of autonomy perceived by the individual General Managers who answered the question, is indicative of the sensation of a not fully autonomous strategic space but, for many aspects connected to the directions and constraints imposed by the central government, is in line with a logic of government rather than governance. A first descriptive analysis shows how the Emilia Romagna Region always falls above the mean value and has, however, an elevated degree of autonomy (table 4). This is true not only for the items relative to the operative autonomy, that is, those referring to a day-to-day management, but also, and above all, to the strategies ones, that is, those referring to the definition of targets and strategic planning. This goes to show how, in spite of the directions and regional mandates, the health organisations participate in an active manner in both the strategic and operative decisions. Lombardy instead, like Piedmont, shows a very limited degree of strategic autonomy of the management. This observation is particularly interesting above all for Lombardy, the region that stands out for having promoted the governance model closest to the quasimarkets, in terms of competitive incentives, public-private equalization and purchaser/provider split but, probably because of this policy choice, it has paradoxically reduced the management role to avoid a situation that could be out of control. . 12 Table 3 – Management autonomy: frequency of the responses Setting _ targets Frequency Strategic _ planning Valid Percent Cumulative Percent Frequency Valid Percent Management Cumulative Percent Frequency Valid Percent Cumulative Percent No autonomy 8 12,31% 12,31% 5 7,58% 7,58% 4 6,06% 6,06% limited autonomy 26 40,00% 52,31% 31 46,97% 54,55% 17 25,76% 31,82% high autonomy 26 40,00% 92,31% 25 37,88% 92,42% 33 50,00% 81,82% full autonomy 5 7,69% 100,00% 5 7,58% 100,00% 12 18,18% 100,00% Total 65 100,00% 66 100,00% 66 100,00% Missing 2 1 1 Total 67 67 67 Procurement Capital _ asset Human_resourses Frequency Valid Percent Cumulative Percent Frequency Valid Percent Cumulative Percent Frequency Valid Percent Cumulative Percent No autonomy 3 4,55% 4,55% 16 24,62% 24,62% 7 10,61% 10,61% limited autonomy 22 33,33% 37,88% 30 46,15% 70,77% 28 42,42% 53,03% high autonomy 22 33,33% 71,21% 18 27,69% 98,46% 28 42,42% 95,45% full autonomy 19 28,79% 100,00% 1 1,54% 100,00% 3 4,55% 100,00% Total 66 100,00% 65 100,00% 66 100,00% Missing 1 2 1 Total 67 67 67 13 Table 4 – Management autonomy: comparison of the regions Regions N Mean Std. Std. 95% Confidence Interval for Mean Min Max Deviation Error Lower Bound Upper Bound Setting Lombardy 11 2,0000 0,7746 0,2335 1,4796 2,5204 1 3 target Piedmont 6 2,3333 0,5164 0,2108 1,7914 2,8753 2 3 Veneto 8 2,8750 0,9910 0,3504 2,0465 3,7035 1 4 Emilia Romagna 11 3,0000 0,6325 0,1907 2,5751 3,4249 2 4 Prov. Bolzano 2 3,5000 0,7071 0,5000 -2,8531 9,8531 3 4 Total 38 2,6053 0,8555 0,1388 2,3241 2,8865 1 4 Strategic Piedmont 7 2,2857 0,9512 0,3595 1,4060 3,1654 1 4 planning Lombardy 11 2,5455 0,6876 0,2073 2,0836 3,0074 2 4 Veneto 8 Management Procurement 2,6250 0,7440 0,2631 2,0030 3,2470 2 4 Emilia Romagna 11 2,8182 0,4045 0,1220 2,5464 3,0899 2 3 Prov. Bolzano 0,0000 3,0000 3,0000 3 3 2 3,0000 0,0000 Total 39 2,6154 0,6734 0,1078 2,3971 2,8337 1 4 Prov. Bolzano 2 2,0000 0,0000 0,0000 2,0000 2,0000 2 2 Piedmont 7 2,2857 0,7559 0,2857 1,5866 2,9848 1 3 Veneto 8 3,1250 0,6409 0,2266 2,5892 3,6608 2 4 Lombardy 11 3,1818 0,6030 0,1818 2,7767 3,5869 2 4 Emilia Romagna 11 3,1818 0,7508 0,2264 2,6775 3,6862 2 4 Total 39 2,9487 0,7591 0,1216 2,7026 3,1948 1 4 Veneto 8 0,3239 1,8591 3,3909 2 4 2,6250 0,9161 Emilia Romagna 11 2,9091 0,8312 0,2506 2,3507 3,4675 2 4 Prov. Bolzano 2 3,0000 0,0000 0,0000 3,0000 3,0000 3 3 Piedmont 7 3,1429 0,6901 0,2608 2,5047 3,7811 2 4 Lombardy 11 3,6364 0,6742 0,2033 3,1834 4,0893 2 4 Total 39 3,1026 0,8206 0,1314 2,8366 3,3686 2 4 Capital Veneto 8 1,8750 0,8345 0,2950 1,1773 2,5727 1 3 asset Piedmont 7 2,1429 0,6901 0,2608 1,5047 2,7811 1 3 Lombardy 10 2,2000 0,7888 0,2494 1,6357 2,7643 1 3 Prov. Bolzano 2 2,5000 0,7071 0,5000 -3,8531 8,8531 2 3 Emilia Romagna 11 2,6364 0,5045 0,1521 2,2974 2,9753 2 3 Total 0,1174 2,0253 2,5010 1 3 38 2,2632 0,7235 human Veneto 8 2,1250 0,6409 0,2266 1,5892 2,6608 1 3 resources Piedmont 7 2,4286 0,5345 0,2020 1,9342 2,9229 2 3 Lombardy 11 2,5455 0,8202 0,2473 1,9944 3,0965 1 4 Emilia Romagna 11 2,6364 0,6742 0,2033 2,1834 3,0893 2 4 Prov. Bolzano 2 3,0000 0,0000 0,0000 3,0000 3,0000 3 3 Total 39 2,4872 0,6833 0,1094 2,2657 2,7087 1 4 14 This aspect in reality is a critical area for most structures and also constitutes one of the relevant differentiation elements between public and private organisations. Table 5 shows how, considering a significance level of 5%, the nil hypothesis (an equality of mean values among the regions) is rejected in the case of a degree of autonomy in the definition of the targets and autonomy of the management: this means that there are consistent differences in the analysed regional contexts in these two decisional ambits. If post hoc tests are carried out, using the Dunnett T3 test option to overcome the restrictive hypothesis of non nil variance of the population, it is possible to conduct a second level analysis and therefore to assess the difference between the regions in detail (table 6) in the two cases where it resulted to be significant. The ANOVA post hoc test carries out a coupled comparison between the individual regions and highlights any significantly different behaviour (that is, significantly different mean values), with a confidence interval of 5%. In the case of a comparison of management autonomy with the targets and the volume of activities, the nil hypothesis was rejected because of a significant deviation between the Lombardy region and the Emilia Romagna region, thus confirming what was mentioned before. As far as the management autonomy is concerned, the ANOVA highlighted that the behaviour of the Autonomous Province of Bolzano diverges from that of the other regions and falls into a significantly lower autonomy level position. Table 5 – Verification of the ANOVA test with a 5% level of significance Setting _ target Strategic _ planning Management Procurement Capital _ asset Human _ resourses Sum of Squares df Mean Square F Sig. Between Groups 8,371 4 2,093 3,6913 0,0137 Within Groups 18,708 33 0,567 Total 27,079 37 Between Groups 1,564 4 0,391 0,8483 0,5046 Within Groups 15,667 34 0,461 3,4495 0,0181 2,2751 0,0814 1,5066 0,2229 1,0083 0,4168 Total 17,231 38 Between Groups 6,321 4 1,580 Within Groups 15,576 34 0,458 Total 21,897 38 Between Groups 5,403 4 1,351 Within Groups 20,187 34 0,594 Total 25,590 38 Between Groups 2,991 4 0,748 Within Groups 16,378 33 0,496 Total 19,368 37 Between Groups 1,882 4 0,470 Within Groups Total 15,862 17,744 34 38 0,467 15 Table 6 One way ANOVA, test Dunett T3 Dependent Variable (I) Regions Setting Piedmont (J) Regions Mean Difference (I-J) Std. Error Sig. 95% Confidence Interval Lombardy 0,3333 0,3146 0,9531 -0,6908 1,3575 Prov Bolzano -1,1667 0,5426 0,5652 -9,2362 6,9029 Veneto -0,5417 0,4089 0,8468 -1,9327 0,8494 Emilia Romagna -0,6667 0,2843 0,2649 -1,6123 0,2789 Lower Bound Upper Bound target Lombardy Prov. Bolzano Veneto Piedmont -0,3333 0,3146 0,9531 -1,3575 0,6908 Prov Bolzano -1,5000 0,5519 0,4332 -8,7760 5,7760 Veneto -0,8750 0,4211 0,3901 -2,2673 0,5173 Emilia Romagna -1,0000 0,3015 0,0332 -1,9429 -0,0571 Piedmont 0,5426 0,5652 -6,9029 9,2362 1,1667 Lombardy 1,5000 0,5519 0,4332 -5,7760 8,7760 Veneto 0,6250 0,6105 0,9217 -4,1953 5,4453 Emilia Romagna 0,5000 0,5351 0,9327 -8,2607 9,2607 Piedmont 0,5417 0,4089 0,8468 -0,8494 1,9327 Lombardy 0,8750 0,4211 0,3901 -0,5173 2,2673 Prov Bolzano -0,6250 0,6105 0,9217 -5,4453 4,1953 Emilia Romagna -0,1250 Emilia Romagna Piedmont Management Piedmont Lombardy Prov. Bolzano Veneto 0,6667 0,3989 1,0000 -1,4794 1,2294 0,2843 0,2649 -0,2789 1,6123 Lombardy 1,0000 0,3015 0,0332 0,0571 1,9429 Prov Bolzano -0,5000 0,5351 0,9327 -9,2607 8,2607 Veneto 0,1250 0,3989 1,0000 -1,2294 1,4794 Lombardy -0,8961 0,3387 0,1744 -2,0521 0,2599 Prov Bolzano 0,2857 0,2857 0,9541 -0,8593 1,4307 Veneto -0,8393 0,3647 0,2861 -2,0611 0,3825 Emilia Romagna -0,8961 0,3645 0,2190 -2,1009 0,3087 Piedmont 0,8961 0,3387 0,1744 -0,2599 2,0521 Prov Bolzano 1,1818 0,1818 0,0006 0,5514 1,8123 Veneto 0,0568 0,2905 1,0000 -0,8838 0,9975 Emilia Romagna 0,0000 0,2903 1,0000 -0,9086 0,9086 Piedmont -0,2857 0,2857 0,9541 -1,4307 0,8593 Lombardy -1,1818 0,1818 0,0006 -1,8123 -0,5514 Veneto -1,1250 0,2266 0,0129 -1,9871 -0,2629 Emilia Romagna -1,1818 0,2264 0,0035 -1,9667 -0,3969 Piedmont 0,8393 0,3647 0,2861 -0,3825 2,0611 Lombardy -0,0568 0,2905 1,0000 -0,9975 0,8838 Prov Bolzano 1,1250 0,2266 0,0129 0,2629 1,9871 0,3203 1,0000 -1,0774 0,9637 Emilia Romagna Piedmont Emilia Romagna -0,0568 0,8961 0,3645 0,2190 -0,3087 2,1009 Lombardy 0,0000 0,2903 1,0000 -0,9086 0,9086 Prov Bolzano 1,1818 0,2264 0,0035 0,3969 1,9667 Veneto 0,0568 0,3203 1,0000 -0,9637 1,0774 The mean difference is significant at the .05 level. 16 VAR 2. Degree of external control The GMs were asked to indicate the areas that were subjected to control by the region from among: 1. Financial soundness of the hospital 2. Real estate 3. Labour regulations 4. Correct use of hospital budget 5. Medical equipment 6. Clinical performance 7. Composition & functioning governing bodies 8. Ethical issues 9. Organisational efficiency Graph 1 shows that, in most cases, four areas are subjected to controls: financial soundness, the correct use of the budget, the clinical performances and the organisational efficiency. The indicator relative to the overall level of external control was obtained by summing the number of areas that GM declared to be under monitoring by the region and for which they are considered accountable. If such an indicator has an elevated value, this means the region monitors an elevated number of areas and the value could therefore be the result of a higher level of delegation of the competences. On the other hand, however, an excessive control could limit the strategic actions of the management (Van Kersbergen and Van Waarden, 2004). Graph 1 – The areas subjected to control by the region organizationale efficiency ethical issues comp & funct governing bodies clinical performance medical equipment correct use of budget labour regulations real estate financial soundness 0 5 10 15 20 25 30 35 40 45 17 VAR 3. The stability A relevant result concerns the management stability, a variable that was measured with the number of GMs (or similar figures) that have guided the structure over the last ten years. The normative foresees a mandate for the GM of between 3 and 5 years. From an analysis of the responses, the GMs on average remain in charge for about 3.5 years over a period of 10 years. In reality, the variability among the regions is rather surprising. From the comparison it can be seen that the Autonomous Province of Bolzano appears to be the most stable as it has kept the same GM as head of the hospital structures that responded to the questionnaire for the last 10 years. In other cases, apart from the Veneto region, the GMs were changed three years after receiving the mandate, which is in line with the normative. Although not representative of the region, the Calabria Region case should be pointed out as, on average, a GM remains in charge for about 1 year: this result was also confirmed from a other research (OASI 2004) which showed a mean length of mandate of about 1.5 for the Calabrian situation. The Aosta Valley has also changed 8 GMs in its one hospital over a period of 10 years. VAR 4. Involvement of the doctors The management action, when making choices, can take advantage, apart from the incentives pulled by the external environment (or by the regions), of the know how and the impulses and incentives pushed by the internal environment, in other words, by the professional figures themselves. In order to analyse the degree of involvement of the physicians in the internal decisions of the structure, seven decisional areas in particular were investigated: 1. Allocation of hospital facilities and personnel to departments and/or physicians (e.g. use of operating room) 2. Medical investments 3. Other investments (e.g. buildings, software, …) 4. Long-term strategic planning 5. Setting volume of physician services 6. Appointment and dismissal of hospital physicians 7. Human resources (excl. physicians) The question foresaw four possible answers according to a Likert scale of the type: no involvement, low involvement, high involvement and the physicians make the decisions. Table 7 shows that the area relative to human resources is the one that undergoes the least involvement by the physicians and it has a higher cumulated percentage than 72%. Furthermore, it is usually possible to state that the participation nature gradually diminishes as the decisions go from a strategic level (planning and fixing the volumes) to a more operative one (acquisition of the equipment rather than the informatics components and allocation of the structures and personnel in the departments). This, in reality, is coherent with the traditional organisational and managerial model of the hospitals which see the physicians being more involved in the decisions closely related to their own operative sphere rather than in the overall health organisation. 18 Table 7 – Involvement of the physicians: frequency of the responses Allocation of hospital facilities Medical investment Valid Frequency Percent Cumulative Percent Other _ investment (ICT, software, etc) Valid Cumulative Frequency Percent Percent Frequency Valid Percent Cumulative Percent no involvement 2 3,03% 3,03% 2 3,08% 3,08% 3 4,62% 4,62% Limited involvement 11 16,67% 19,70% 10 15,38% 18,46% 24 36,92% 41,54% High involvement 51 77,27% 96,97% 53 81,54% 100,00% 38 58,46% 100,00% Physicians make the decision 2 3,03% 100,00% 0,00% 100,00% 0,00% 100,00% Total 66 100,00% Missing 1 2 2 Total 67 67 67 Long-term _ strategic planning Setting _ volum 65 100,00% 65 Frequency Valid Percent Cumulative Percent Frequency Valid Percent Cumulative Percent no involvement 3 4,62% 4,62% 9 14,52% 14,52% Limited involvement 30 46,15% 50,77% 26 41,94% 56,45% High involvement 32 49,23% 100,00% 27 43,55% 100,00% 0,00% 100,00% 0,00% 100,00% Physicians make the decision Total 65 Missing 2 100,00% 62 5 Total 67 67 100,00% 100,00% Appointment and dismissal of hospital physicians Human _ resources (excl. physicians) Cumulative Valid Cumulative Frequency Valid Percent Percent Frequency Percent Percent no involvement 23 37,10% 37,10% 13 20,00% 20,00% Limited involvement 24 38,71% 75,81% 34 52,31% 72,31% High involvement 15 24,19% 100,00% 17 26,15% 98,46% 0,00% 100,00% 1 1,54% 100,00% 65 100,00% Physicians make the decision Total 62 Missing Total 5 67 100,00% 2 67 19 Table 8 – Involvement of the physicians in the decisions: descriptive analysis Regions N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Min Max Lower Bound Upper Bound Allocation of Veneto 8 2,625 0,744 0,263 2,003 3,247 1 3 hospital facilities Piedmont 7 2,714 0,488 0,184 2,263 3,166 2 3 Lombardy 11 2,909 0,302 0,091 2,707 3,112 2 3 Emilia Romagna 11 2,909 0,302 0,091 2,707 3,112 2 3 Prov Bolzano 2 3,000 0,000 0,000 3,000 3,000 3 3 Total 39 2,821 0,451 0,072 2,674 2,967 1 3 Medical Prov Bolzano 2 2,500 0,707 0,500 -3,853 8,853 2 3 investment Piedmont 7 2,857 0,378 0,143 2,508 3,207 2 3 Veneto 8 2,875 0,354 0,125 2,579 3,171 2 3 Lombardy Other investment 11 2,909 0,302 0,091 2,707 3,112 2 3 Emilia Romagna 10 3,000 0,000 0,000 3,000 3,000 3 3 Total 2,895 0,311 0,050 2,793 2,997 2 3 38 Piedmont 7 2,429 0,535 0,202 1,934 2,923 2 3 Prov Bolzano 2 2,500 0,707 0,500 -3,853 8,853 2 3 Veneto 8 2,625 0,518 0,183 2,192 3,058 2 3 Lombardy 11 2,818 0,405 0,122 2,546 3,090 2 3 Emilia Romagna 11 2,909 0,302 0,091 2,707 3,112 2 3 Total 39 2,718 0,456 0,073 2,570 2,866 2 3 Long-term Veneto 7 2,286 0,756 0,286 1,587 2,985 1 3 Strategic Prov Bolzano 2 2,500 0,707 0,500 -3,853 8,853 2 3 planning Piedmont 7 2,714 0,488 0,184 2,263 3,166 2 3 Lombardy 11 2,727 0,467 0,141 2,413 3,041 2 3 Emilia Romagna 11 2,727 0,467 0,141 2,413 3,041 2 3 Total 38 2,632 0,541 0,088 2,454 2,810 1 3 Veneto 7 2,143 1,069 0,404 1,154 3,132 1 3 Piedmont 6 2,333 0,516 0,211 1,791 2,875 2 3 Lombardy 11 2,545 0,522 0,157 2,195 2,896 2 3 Emilia Romagna 11 2,636 0,505 0,152 2,297 2,975 2 3 Prov Bolzano 2 3,000 0,000 0,000 3,000 3,000 3 3 Total 37 2,486 0,651 0,107 2,270 2,703 1 3 Appointment Veneto 7 1,571 0,787 0,297 0,844 2,299 1 3 physicians Emilia Romagna 11 2,000 0,632 0,191 1,575 2,425 1 3 Lombardy 11 2,182 0,874 0,263 1,595 2,769 1 3 Piedmont 6 2,333 0,516 0,211 1,791 2,875 2 3 Prov Bolzano 2 3,000 0,000 0,000 3,000 3,000 3 3 Total 37 2,081 0,759 0,125 1,828 2,334 1 3 Human resources Veneto 7 1,714 0,756 0,286 1,015 2,413 1 3 (excl. Physicians) Emilia Romagna 11 2,000 0,447 0,135 1,700 2,300 1 3 Piedmont 2,286 0,951 0,360 1,406 3,165 1 3 Setting volume 7 Lombardy 11 2,545 0,522 0,157 2,195 2,896 2 3 Prov Bolzano 2 3,000 1,414 1,000 -9,706 15,706 2 4 Total 38 2,211 0,741 0,120 1,967 2,454 1 4 20 ANOVA, in this case, did not reveal any significant difference in the answers from the different regions, but it is still possible to make some comments on the different regions. Table 8 shows how, with the exception of the investments, the Veneto Region has resulted to be the region with the lowest level of involvement in each area that was analysed, above all as far as the most strategic functions are concerned. Apart from the involvement in the management of the human resources, Lombardy, in spite of a low involvement of the strategic decisions by the management in comparison with the region, shows a high degree of involvement of the medical personnel working inside the organisation, in a logic that is closer to governance and to the “creation of consensus” than to a hierarchical-bureaucratic model. A similar tendency was also witnessed in the Emilia Romagna Region, a tendency which is coherent with the governance style that characterises the regional system. VAR 5. Transparency of information If the degree of involvement of the doctors in the decisional processes is elevated, it can be expected that the professional figures in the health service who work inside the organisation should be able to take part in the decisions as they have, however, a wide vision of the management tendency of the organisation. In order to measure the tendency of the management to make the doctors more aware of their decisions, the GMs were asked which of the following information forms are directly accessible to the physicians (or indirectly, through their representatives) who work in their structure: 1) meeting reports of the governing bodies of the hospital 2) hospital budget specifications 3) annual financial statements of the hospital 4) hospital activity data 5) external assessment reports Graph 2 shows how, in almost all the structures, both the data relative to the budget (86.57%) and the activities of the structure (91.04%) are at the physicians disposal; the percentage diminishes slightly for the transparency of the data relative to the annual balance (about 73%), while less than half those who answered make the data relative to the minutes of the meetings of the governing bodies (about 41%), or to the relationship with external subjects (about 32%), available to the physicians. It is important to point out that the survey made it possible to monitor the accessibility to the information by the physicians, but gave no information on the capacity of the doctors to utilize this information or even on their capacity to understand the contents (for example, the capacity of the medical personnel to read a balance sheet could have different effects as they are not required to understand the contents). The overall number of documents declared accessible was considered in order to identify a synthetic indicator of the information within the organisation. This kind of solution sacrifices the specificity of the information that is available to the personnel, but this is in part justified by the fact that the accessible information however concerns the previously specified categories (that is, data on the structure, data on the budget and the annual balance sheet). 21 Graph 2 – Transparency of the information: the distribution of the responses external assessment reports 22 hospital activity data 61 balance sheet 49 hospital budget 58 meeting reports 28 0 6.2 10 20 30 40 50 60 70 Cluster analysis: governance structures A cluster analysis allows groups of relatively homogeneous cases to be identified on the basis of certain chosen characteristics, utilizing an algorithm that begins with each case in a distinct cluster and which combines the various cases in a final cluster. On the basis of the centre assumed by each variable for each cluster, a qualitative measure was assigned to each value according to a scale that went from very high to very low and in the end the characteristics of the governance of the two levels (external and internal) were defined according to this criterion. The external governance, according to the degree of autonomy of the management from the regional government and to the number of areas subjected to control, assumed three different characteristics: o government, which involves a close tie with the region both for the strategic management aspects and the operative ones and a medium degree of control; o quasi-government, which is characterised by a degree of autonomy connected above all to the operative management and less to the strategic aspect; o governance, which is characterised by an elevated degree of autonomy, but also a medium-high regional control (table 9). 22 Table 9 – external governance Variables external governance quasi government government governance Level of external low authority medium-low high Degree of external control medium low mediumhigh In the same way, the models that emerged for the internal governance showed three different characteristics: o a hierarchical approach, which shows an autocratic leadership model, with a low degree of involvement by the physicians in the organisational processes and a lack of a participation culture; o a quasi-participative approach, which is different because of the greater involvement of the doctors, and is a consultative leadership model even though the transparency of the organisation, and therefore of the organisational strategies, still seems limited; o a participative approach, which is a leadership approach with great emphasis on negotiation and participation, and means a diluted decisional power (table 10). Table 10 – Internal governance Variables Internal governance semihierarchical participative participative low medium medium medium-low high high medium Involvement of the physicians Transparency in the information medium-low Stability in the management low 23 The combination of the different approaches led to the identification of nine governance models (table 11). Table 11 – The diffusion of governance models Internal governance hierarchical governance External quasigovernance government government semiparticipative participative 1,79% 14,29% 32,14% 1,79% 8,93% 25,00% 3,57% 3,57% 8,93% An analysis of the external governance models has shown an elevated autonomy with respect to the central government in 48% of the cases with a more or less accentuated degree of control. These models are present to a significant extent both in Lombardy and also in Emilia Romagna, even though they are the result of different regional policies. The elevated degree of autonomy in Lombardy derives from the purchase/provider split, with consequent transformations of all (or almost all) hospital under ASL direct management into autonomously managed hospital organisations. The equalization between public and private structures has created conditions similar to those of a quasi-market. From this point of view, the region covers the financer’s role, through the ASLs, and of controller of the system, leaving the organisations a greater freedom of action, which is however in part limited by the mandate and regional policies. As far as the areas subjected to control are concerned, the financial area results to be monitored and there is a correct use of the budget. In Emilia Romagna, the resulting governance model (60% of the cases) is the result of a regional policy of creating a model of networks and not of quasi-markets, with a great incentive towards participation and cooperation between the actors in the system, that is, between the hospital organisations (and hospital under ASL direct management) and the regional government, both in the planning of the offer of services stage and in the overall organisation of the system. In this case, the cooperation element substitutes the competitive element. This also explains the percentage of 40% of those who, though feeling the presence of the regional government as a constraint to the expression of their decisional power, are part of the logic of quasi-government. If we go further into detail, the analysis of the responses surprisingly highlights how the regional interference is felt above all in the operative management areas (management, procurement, human resources) rather than in the strategic areas: this would explain the use of negotiation, but also the disposition of norms and directives that have to be followed which, to some extent, help to undermine the free governing action of the 24 management. In this case, the region covers the role of pivot and arbitrator of the system. The surprising result, however, is that, in spite of the subsequent wave of reforms and the incentive towards “managerialism” process, the percentage of structures that have maintained a close connection with the regional government is very high: there are still many situations in which the region’s interference in agency policies is still very high and the strategic action perceived by the general managers is limited. A persistent logic of (quasi-) government that controls the relationship between the local government and the management of the structure in fact exists (51%). This is the case, for example, in the Veneto region where the region plays the role of a real holding in its relationship with the health organisations. In this case, there is in fact no negotiation but rather a consultation of the organisations: the decisional power concerning policies and strategies however remains in the hands of the region. A similar situation exists in the Autonomous Province of Bolzano. Although not representative of the health organisations in the South, it is perhaps indicative that 85% of the southern structures that have taken part in the research mentioned a (quasi-) governmental logic in their relationship with the regional government, where the regional interference exists at both a strategic and an operative level. It was also clearly shown that in the Molise case this logic seems even more pronounced after all the ASLs were joined into one single regional ASL (ASREM), which, though autonomous from the management point of view, is directly connected to the regional government. In this context an opposite situation is found in comparison to the reforms carried out to decentralise the functions: the concentration of the power has been re-established, as in the past, in the hands of the Region. Going on to analyse the internal governance, it is obvious that there is a net prevalence of participative models for the involvement of the physicians in the decisional processes of the organisations. This involvement, however, is sometimes not followed by a policy of transparency of information and therefore of sharing the vision, strategies and organisational objectives (semi-participative governance). Furthermore, in some cases, the possibility of sharing the organisational policies and of participating in the management of the organisation is compromised by an elevated degree of managerial instability. The hierarchical model instead was only found in the Calabria region (which also had the highest rotation rate of the GM over the 10 years) and in the Aosta Valley. In the case of governance approach (at an external level), the management tendency is instead that of transporting the same participative logics into the organisation, moving towards making the medical personnel more responsible, a sharing of decisions and a tendency to develop negotiation and discussion tables. In these cases, the process of persuasion and the ability to induces a group (physicians and medical staff) to pursue objectives held by the general managers are crucial ingredients for an effective leadership (Druker 1992; Gardner 1990). The processes therefore take place both at a regional and an organisational level according to bottom-up logics. Furthermore, the presence of a net majority of semi-participative and participative models at a full level compared to a governance presence of less than 50% would lead one to believe that the organisations are more capable of making use of innovative governance and participative models than the regional governments. 25 7. Discussion and conclusions The research has highlighted a great variability in the governance models adopted by the health structures, together with a heterogeneity in the policies and strategies at a regional level. One of the most important aspects concerns the delay in acknowledging the intentions of the national legislator about market-based approach and entrepreneurial process of the health structures and of the limited strategic space of these healthcare organizations. This makes it possible to understand how the maturation and growth process towards more innovative governance approaches that leave behind traditional government models in favour of the development of participated, transparent and shared governance logic which is able to respond to the real characteristics of the hospital structures, defined as “producers’ cooperative” (Ackroyd et al. 2007), is still far from complete. As in the past, in many regions there is a concentration of the power at regional level, compromising competition (quasi-market models) and negotiation and collaboration (network-based models) between the actors in favour of a (quasi-) government approach (hierarchical models). These tendencies limit also the leadership skills of the general managers: it is difficult to manage a dream (Bennis 1989) when there are a lot of constrains, norms and mandates both at strategic and operational level. Only in the network-based models there is a governance logic at external level, while when a quasi-market model emerges at regional level (Lombardy) there is limited strategic space for general managers but an high degree of autonomy at operational level. According with Farrell and Morris (2003) the “marketized” system is equally dependent upon bureaucracy and the apt term for this new state model is “neobureaucratic” or “bureaucratic market form”. Nevertheless, in the cases of Lombardy (quasi-market model) and Emilia Romagna (network model), general managers have shown to adopt a more participative leadership, according with a governance logic and a modern management-style. A crucial aspect is the stability of the management: the political interference (in fact, by law, regional government appoints general management) could limit the governability of the healthcare organizations and, also, the possibility to implement long-term strategies. 26 Bibliografia Achard, P.O. 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