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. Castello,V. e Profili, S.
2000 “Lo spazio strategico: una valutazione empirica”, in Fontana, F. Lorenzoni, G. (a cura
di), L’architettura strategica delle aziende sanitarie: una analisi empirica,
FrancoAngeli, Milano.
Achard, P.O. Cicchetti, A. e Profili, S.
2000 “La formazione delle strategie nelle aziende sanitarie”, in Fontana, F. Lorenzoni, G. (a
cura di), L’architettura strategica delle aziende sanitarie: una analisi empirica,
FrancoAngeli, Milano.
Ackroyd, S. Hughes, J. and Soothill, K.
1989 Public Sector Services and their Management, in Journal of Management Studies, 26, 6,
pp. 603-19
Ackroyd, S. Kirkpatrick, I e Walzer, R.M.
2007 Public management reform in the UK and its consequences for professional
organization: a comparative analysis, in Public Administration, vol 85. n.1, pp.9-26
Bartlett, W. Le Grand, J.
1993 Quasi-Markets and Social Policy, MacMillan, London, pp.13-34.
Bennis, W
1989
On becoming a leader. Reading, MA, Addison-Welsey.
Borgonovi, E.
2002 Principi e sistemi aziendali per le amministrazioni pubbliche, Milano, Egea.
Bosi, P.
2006 Corso di Scienza delle finanze, Bologna, Il Mulino.
Brudney, J.L. O’Toole Jr, L.J. e Rainey, H.G.
2000 Advancing public management: new developments in theory, methods and practice.
Washington, DC, Georgetown University Press
Cicchetti, A.
2004 La progettazione organizzativa. Principi, strumenti e applicazioni nelle organizzazioni
sanitarie, FrancoAngeli, Milano.
Druker, P.F.
1992 Managing for the Future: The 1990’s and Beyond, New York, Truman Talley.
Eeckloo, K. Van Herck, G. Van Hulle, C. Vleugels, A.
2004 “From Corporate Governance To Hospital Governance. Authority, Transparency and
Accountability of Belgian non profit hospitals board and management”, in Health Policy,
vol. 68, pp 1-15.
Farrell, C. e Morris, J.
2003 the ‘Neo-Bureaucratic’ State: Professionals, Managers and Professional Managers in
Schools, General Practices and Social Work, in Organization, vol 10, pp. 129156.
27
Feldman, M.S. e Khademian, A.M.
2002 “To manage is to govern”, in Public Administration Review, vol. 62, n. 5.
France, G.
2001 Evolution of Health Care Reform in Italy, European Health Care Discussion Group,
First draft, Second Meeting, London School of Economics
France, G. Taroni, F. e Donatini, A.
2005 “the Italian health-care system”, in Health Economics, vol.14, pp. S188-S202.
Gardner, J. W.
1990 On Leaderhip, New York, The Free Press.
Heinrich, C.J. e Lynn Jr. L.E
2000 Governance and Performance: New Perspectives. Washington, DC: Georgetown
University Press.
Hill, C.J. Lynn Jr, L.E.
2004 “Governance and Public Management, an Introduction”, in Journal of Policy Analysis
and Management, vol. 23, n. 1, pp. 3-11.
Hirst, P.
2000 “Democracy and governance”, in J. Pierre (ed.), Debating governance: Authority,
steering and democracy, Oxford: Oxford University Press.
Hood, C.
1991 “A public management for all seasons?”, in Public Administration, n. 69, 3-19.
1995 “The ‘New Public Management’ in the 1980s: Variations on a theme”, in Accounting,
Organizations and Society, vol.20, n. 2/3, pp. 93-109.
Kickert, W. J. M
2001 “Public management of hybrid organizations: governance of quasi-autonomous
executive agencies”, in International Public Management Journal, Vol. 4, pp 135-150.
Klein, R.
1989 The Politics of National Health Service, 2nd edn. London, Longman.
Lane J. E.
2000 New Public Management, London, Routledge.
Le Grand, J.
2003 Motivation, agency and public policy: of knight and knaves, pawns and queens, Oxford,
Oxford University Press.
Light, D.
1997 From Managed competition to managed cooperation: theory and lesson from British
experience, in Milbank quarterly, vol.75, n.3, pp 297-341.
Lynn Jr, L.E.
1998 The new public management: how to transform a theme into a legacy, in Public
Administration Review, vol. 58, n. 3, pp231-238.
28
Lynn, Jr.L E., Henrich, C e Hill. C. J.
2001 Improving Governance: A New Logic For Empirical Research. Washington, DC:
Georgetown University Press.
McKee, M e Healy, J.
2002 “The significance of hospitals: an introduction”, in Figueras, J. McKee, M. Mossialos,
E. e Saltman, R., Hospital in a changing Europe, European Observatory on Health Care
System Series, Buckingham-Philadelphia, Open university Press.
McNulty, T. e Ferlie, E.
2004 “Process transformation: limitations to radical organizational change within public
service organizations”, in Organization Studies, vol. 25, n. 8, pp. 1389-1412.
Metcalfe, L.
1993 “Public Management: from imitation to innovation”, in Australian Journal of Public
Administration, Vol. 52, n. 3. September.
Minogue, M. Polidano, C. e Hulme, D.
1998 Beyond the new public management: changing ideas and practices in governance,
Cheltenham, Edward Elgar.
Mintzberg, H.
1993 Structure in fives: designing effective organizations, Prentice-Hall, New Jersey
Newhouse, J. P.
1970 “Toward a theory of nonprofit institutions: an economic model of a hospital”, in The
American Economic Review, pp. 64-74.
Osborne, D. e Gaebler, T.
1992 Reinventing government: how the entrepreneurial spirit is trasforming the public
sector, Reading, MA, Addison-Wesley.
Pollitt, C. e Bouckaert, G.
2000 Public management reform: a comparative analysis, Oxford, Oxford University Press.
Van Kersbergen, K. e Van Waarden, F
2004 “’Governance’ as a bridge between disciplines: cross-disciplinary inspiration
regarding shift in governance and problems of governability, accountability and
legitimacy”, in European Journal of Political Research, vol. 43, pp 143-171.
Yin, R.K.
1994
Case study research. Design and Methods, 2nd Ed., Applied social research method
series; vol.5, Sage publications.
29