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CONFERENCE PROCEEDINGS
13th Toulon-Verona Conference “Organizational Excellence in Services”
University of Coimbra (Portugal) – September 2-4, 2010
pp. 931-944 – ISBN: 978-972-9344-04-6
Riccardo Mercurio
Professore Ordinario di Organizzazione Aziendale
Università degli Studi di Napoli Federico II
Dipartimento di Economia Aziendale
[email protected]
Marcello Martinez
Professore Ordinario di Organizzazione aziendale
Dipartimento di Strategie aziendali
Seconda Università degli Studi di Napoli
www.strategie.unina2.it
Caterina Galdiero
Dottore di ricerca
Università degli Studi di Napoli Federico II
Dipartimento di Economia Aziendale
[email protected]
Marina Cerbo
Direttore del dipartimento innovazione e sviluppo
Agenas – Agenzia Nazionale per i Servizi Sanitari Regionali
[email protected]
Maria Rosaria Perrini
Sezione ISS - Innovazione, Sperimentazione e Sviluppo
Agenas - Agenzia Nazionale per i Servizi Sanitari Regionali Agenas
[email protected]
Organization, governance and managerial control of public and private:
the analysis of organizational mechanism maturity.
1. Introduction
In 1992 in the public sector a thoughtful transformation started by a process of structural
reforms that involves the whole public administration. In particular, in the Italian health
system, the institutional changes, the introduction of new technologies, the evolution of
epistemological framework, the increase average age of the population and also the increase
of service costs have determined during the years big changes. In this context was born the
need to introduce new tools and models of service management capable of combining the
quality of health care with the containment of costs of the activities (Rebora et all, 2007,
Anselmi, 1997, 2003, Borgonovi 2000, 2002, Factor, 2004, League, 2006, Anessi Pessina,
Canterbury, 2007).
In recent years, most public health authorities have launched operations of outsourcing of
their activities, partnerships with private entities for the development of investments, for the
institutional changes (creation of foundations, joint ventures etc.. ) and service management
(Amatucci, et all, 2006.2007, Cappellaro, Marsilio, 2007, Cuccurullo, Tommasetti, 2002).
The health is trying to find models of governance of inter- and intra-organizational
relationships able to simultaneously solve the growing phenomena of specialization and
needs of autonomy integration. These operations are designed to streamline and enhance the
supply of services through a reshaping and management of relationship of different actors
(Del Vecchio, 2003, Male, 2009, Cicchetti et al, 2006, League, 2006).
Numerous studies about governance have contributed to analyze the innovation
phenomenon of logic system and management practices in Public Administration
(Meneguzzo, 1995, 1997, 2000). This work is focused on the analysis of a particular
phenomenon of innovation in the health management of trials.
2. Theoretical framework
The topic of governance, even if it was a study subject in various disciplines, has own
contributions in the economic and social policies sciences regarding specifically the
governance of companies and public administrations. An analysis of national and
international literature shows that despite the national and international wide spread, the issue
of public governance presents wide uncertainty and is not always clear interpretated (Cepiku,
2005; Bovaird and Loffler, 2001, 2002). In fact, even in healthcare the governance can take
on different meanings and shows itself in different ways.
However, it is possible to synthesize at least three different meanings (Longo 2005,
Cepiku 2005, Meneguzzo 1997, Rhodes, 1992, 1996, 1997, 1998, 2008, Stoker, 1998, Pierre,
2000; Kickert, 1997, 2000, 2003, Stoker, 1998; Lynn, 2003; Bovaird and Loffler, 2002;
Mayntz, 2003):
a) a first use is attributed to the trend of corporate governance and it is applied to the analysis
and design of operating rules into institutions and their internal organs; in particular in the
business companies it regards the regulatory mechanisms of contributions and rewards
obtained by all stakeholders;
b) other definition oppose the term "governance" to the term "government" to highlight how
the government outweighs the direct production of services, while in the governance prevails
the tools guide, the promotion and influence of corporate processes. "The logic of
government exercises powers mainly at higher-level, adopting an authoritarian style,
focusing on the formal principle. The logic of governance plays a leading role in regulating
economic activities and guidance to other entities (which govern them caught the market),
favoring consensus principles and criteria of economy and functionality of the 'practicability'
technical, organizational economic, social (Borgonovi 2002);
c) A third approach is the public Governance focuses on the public interest networks and
seeks to promote the social utility and effectiveness of all institutions (including private) that
somehow affects the public interests, trying to interconnect in a collaborative logic all the
forces, Public Administration and society.
In this context we will use the first approach starting from a first useful definition,
“corporate governance is concerned with ways of bringing the interests of investors and
managers into line and ensuring that firms are for the benefit of investors "(Mayer, 1997:
154). In this sense, it represents a set of mechanisms and procedures designed to streamline
and harmonize the interests of investors in relation to those managerial structure, that are
different. The objective is to protect shareholders against the work of a leadership with their
own interests, even though not necessarily conflicting or contradictory to those of investors.
A different definition is offered by Deakin and Hughes whose corporate governance 'Is
concerned with the relationship between the internal mechanics of corporate governance and
society's conception of the scope of corporate accountability "(Drakin Hughes 1997: 2). In
this case the one hand it refers more properly to the internal mechanisms that constitute the
functioning; at the other hand, the company generally understood as the whole system of
ownership and leadership, which is what defines the purpose and limits of corporate
accountability.
A different and broader definition is offered by Keasey and Wright, according to the
subject of corporate governance includes all those "structures, processes, cultures and
systems that engender the successful operation of the organizations” (Keasey, Wrigh, 1997 ).
The items to be considered, then, are different from competing even if united from their
actions to the success. These definitions are now categorization more widely accepted, but in
general, corporate governance systems as those mechanisms - economic and legal - aimed at
defining the nature of the property (ownership) and control organization (Cook, Deakin,
1999).
Therefore, corporate governance concerns those processes of self – regulation and then
award standards as well as self-control procedures and verification - through which makes it
more efficient, more transparent and secure the work of the corporation for the benefit of the
actors involved (Rossi, 2003: 71-97).
An important aspect is the difference between shareholders and stakeholders. In the narrowest
interpretation of corporate governance are not only the interests and benefits of the
shareholders to guarantee and the processes on which to build accountability and oversight. In
broader governance models, however, all stakeholders – i.e. all those who have an interest in
the choices made by the company - must be properly considered actors. In the early '80s the
stakeholders were considered those which could affect the company or were affected by it
(Freeman, Reed, 1983, Freeman 1994, Freeman, Evan, 1990), the most recent definitions have
attempted to restrict meaning. Donaldson and Preston believe that all stakeholders are those
who have a moral interest in activities (Donaldosn, Preston, 1995). More recently are defined
stakeholders “Those whose relations to the enterprise can not be contracted for completely, but
whose cooperation and creativity depends upon for its survival and prosperity "(Slinger,
Deakin, 1999: 1), including all those who are directly engaged in an employment relationship
with the commercial or financial undertaking. Shareholders, lenders, management, partners,
employees and in some ways even customers, suppliers, retailers, are all actors engaged in
different stages of corporate governance.
Only from the definition of the actors is possible to establish the principles of accountability
which, when respected, and when able to guarantee the success of the company, are a good
governance. Particularly important in this regard is the establishment by the Organization for
Economic Cooperation and Development (OECD, 1999) of Principles on Corporate
Governance, established as the principles and standards of good corporate governance and
transparency arise from the need to see guaranteed and accountability in the governance of
corporations.
3. The institute of “sperimentazioni gestionali” in Italy
Also in the health sector have been established programs aimed to removing constraints to
entry of private systems of financing and delivering health services. The process of
innovation in healthcare aims primarily to bring down a system more in line with the new
logical and new requirements of socio-economic system changing (Borgonovi 2002;
Amatucci et all, 2007; Cappellaro, Marsilio 2007; Galdieri 2009).
The forms of health public-private collaboration were introduced by the Institute of clinical
management. The rules regulating the form of public-private collaboration in health care has
evolved significantly since 1991, which were imposed by Art. 4, paragraph 6, of the Law. No
412/1991, and Art. 10 of Legislative Decree 19 June 1999, No 229 which amended Art. 9 bis
of Legislative Decree 30 December 1992, No 502 indicating the possibility of using publicprivate joint ventures in some trials and introducing guarantees such as the roof of 49% of
capital allocated to the private (Cuccurullo Tommasetti, 2002, Faillace 2005, 1997 Anselmi,
Amatucci, Lecce 2006, ASSR 2004). Neither the Article 4 mentioned, nor the article 9 bis of
Legislative Decree No 502/1992, which specifies the rules and complete trials, give a more
precise "definition" of experimentation, it is underline that these should only be undertaken
to seek more efficient models of government health spending and improving the quality of
healthcare1.
The collaboration between public and private entities may have as subject both the direct
exercise of core business and the management of non-core or peripheral services: hotel,
meals, real estate, technical services. According to this distinction, the joint ventures is the
experience of collaboration that has as object the health activities, otherwise, there is a
simple operation of partnerships (outsourcing of activities; global service, etc.. From the
point of view legal joint venture have resulted in models based on convergence of interests
between public and private sector and aimed at the pursuit of joint economic and social
objectives, from which individual participants derive indirect individual benefits. The
precondition for the success of these reports is a significant involvement of various partners,
which is expressed with the contribution and exchange of capital and financial resources,
scientific expertise and management, human resources, competencies, organizational
flexibility, managerial and companby skills (Galdieri, Cicellin 2009; Tommasetti and
Cuccurullo, 2002)).
In the Italian context, the tool of joint venture include a wide range of collaboration forms
between public and private actors. In particular, it is possible to bring back the kind of
experimentation with different contractual relationship variations (Pessina, Canterbury,
Value OASIS 2007): the creation of a mixed public-private, in the form of limited liability
companies or limited liability company, or in the consortium form of companies,
establishment of a foundation for participation, participation in an agreement association,
contract award and construction management, contract award and construction management
with project finance, sponsorship agreement (Amatucci et all, 2007). The legal form mainly
used which has particular characteristics and specifications is the joint venture public-private
partnerships. This organizational model can exploit all the advantages of a private business
entity exploiting the characteristics of flexibility both in finding financial resources and in
personnel management, asset management respecting rules also provided for civil society
capital but operating in a public network system. The forms taken into consideration are
limited liability companies and limited liability consortium. The first two are the most
widespread in the Italian context.
The power to authorize these hybrid forms is provided by the Government and the
Regions at which is also recognized the power to "institutionalize" the results of trials after
the first three years with the conclusion of the experience or the formalization on the basis of
final results.
The legislation introduced so far has shown a strong bias against the phenomenon of joint
ventures, even if at one side seemed to want to open up to innovative market logic and rules
of other legislation has greatly restricted the proliferation of forms of public-private
management in healthcare. A turning point occurred in 20012 when the regions have the
power to adopt programs for testing only giving notice to the responsible Ministry with
obligation to draw up an annual report on the results until all federal specifications. With this
act, starting from initial concerns and rigidity, has led to a more pragmatic solution: to
recognize the competence of the Regions and delegate to them the formulation of programs
of experimentation more appropriate and consistent with your health plan, coherently with
the federal process. It has, therefore, to the regions an additional tool to address the
complexity of the sector.
4. The research
4.1 The objectives of the work and search methodology
The phenomenon is experimental and not defined still, so the objective of this study was
to investigate the degree of maturity of organizations forms adopted for corporate
governance and managerial control of mixed public-private partnerships in health.
In particular, research has investigated the level of organizational maturity (Burns et all
2002; Rosenstack, 2002, Cooke, 2004; Pennypacker, 2002) of public-private joint ventures,
based on identification of key processes relevant to the management of joint ventures and
detection systems, organs, organizational arrangements and procedures adopted for their
control, to check what systems of governance and management control able to meet the
different public and private stakeholders to attain different objectives and interests.
The research was based on building a conceptual model of analysis of the maturity of
organizational governance and control systems and a field survey based on company visits,
analysis of company documentation and semi-structured interviews with heads of companies.
The project team carried out an exploratory analysis of joint ventures. Institutionalized forms
of experimentation were analyzed, those which created a third party in the form of limited
liability companies (Spa, Ltd.) in the Italian regions, in agreement with Agenas. The publicprivate joint ventures surveyed during fieldwork were 10 (representing the universe of
public-private joint ventures in health in the Italian context): Orthopaedic Center of Quadrant
spa, Madonna del Popolo Hospital Omegna, Omegna (VB ) Amos srl, Cuneo, Institute
Codivilla Putti Spa, Cortina (BL) High Specialization Spa Rehabilitation Hospital, Motta di
Livenza (TV) Ltd IRST Meldola (FC) Montecatone spa Imola (BO), New Civil Hospital of
Sassuolo (MO) ISMETT srl, Palermo, Prosperius Tiberino spa Umbertide (PG) Montefeltro
Health Ltd, Sassocorvaro (PU).
The exploratory study has contributed to the identification and specification of sensitive
"type" organizational processes and to the identification of qualitative indicators for the
assessment of organizational maturity (DeCastro 2008; Burns et all 2002; Rosenstack, 2002,
Cooke, 2004; Pennypacker , 2002, Cooke et all, 2002).
For each company was determined the presence or absence of each type of organizational
process and the procedures for execution of it. The analysis and study about how to perform
each process has emerged from the interviews during which it was described the way of
implementation of the organizational process and the study of corporate documents that
testify the level of formality and rigor in the execution. The activity of survey was preceded
by an preliminary activity on all available documentation and budgets for each company,
available from induced sources. After this visits were made directly to the social and
operational structures. During the meetings were conducted semi-structured interviews with
administrative and medical directors, the CEO, the CEO and/or company President.
In every entity and regional governments has been requested documentation useful to study
the phenomenon to contribute to the modeling of different experiments within a common
organizational framework.
4.2 Joint ventures cases in Italy
Before the starting to analyze the degree of maturity of the organizational steps we show
the comparison of the characteristics of ten business realities from the investigation.
The analysis of cases shows that the process of experimentation definition is a bottom-up
process that comes from the need of the Local Health Units (ASL) or local communities,
following specific regional reorganization of health systems.
The question of the experimentation length is, in all cases analyzed, a serious problem.
From analysis emerges that in the majority the cases are extended beyond the experimental
period (over three years), this is often determined by an uncertainty at central level in relation
to how to evaluate their achievements and stabilization of the same tests. Indeed, at the end
of the time both national and regional regulations are often unclear about that. Although in
some cases have already been identified pathways of transformation experiments.
Another aspect emerged from the analysis is the composition of the corporate structure in
which there are, in addition to private shareholders, the ASL. This could lead to problems
arising from the dual role assumed by the public entity. Occurs, essentially, a situation in
which the controller is also controlled.
On the type of private shareholders to be made a reflection. Among these there is a high
heterogeneity: private financial members (banking foundations), private shareholders
belonging to Italian groups working in the field of facilities management and health services,
private shareholders belonging to international groups active in the management of facilities
and health services; private members partners from the NGO sector. They are mostly people
who are already working in the health sector. Among the reasons that may justify the
intervention of these individuals in a joint ventures there are those attributable both to
intervention strategies aimed at ensuring the territory, acting in common on which the new
company, an appropriate level of care, and strategies development supported by a
strengthening of its positioning and corporate image, and the ability to enter from abroad, in
the Italian sector.
The heterogeneity of the underlying reasons emerge by viability analysis conducted on the
ten joint ventures. In fact, often it is found that the presence of profits to justify an adequate
return on invested capital is not considered a prerequisite for continued participation in
society. That may be checked both obligations reinvestment of profits, the conditions that
guarantee the absence of profits, and the presence of a minimum return for safeguarding the
needs of economic balance sheet of the company over the medium term: condition, already
pointed above, that appears to be indispensable to avoid assumptions of aid by the State. In
the real facts emerges the role of private partners participating in joint ventures as actors
carrying on management experience and professionalism, as well as to financers. Indeed, to
the private partner is given the role as manager, leaving a broad margin of discretion, such as
the appointment of the managing director or director general, while the strategic direction
remains in public hands. The need to balance the diverse needs of public and private partners
has resulted in customer solutions.
Coherently with the ratio of experimentation management the activities from ten joint
ventures are mainly core, only one case with non-core activities, which in fact has been
transformed after three years 100% owned company. The complexity of the activities is an
important factor affecting the economic and financial situation. At the joint ventures is given
a more complex structure in which there are activities and services not fully predictable as a
result of emergencies or unforeseen events (emergency room or transplantation, for
example), reconciliation between objectives of Economic Financial balance predictable ex
ante and satisfying of public needs is more difficult.
4.3 The relevance degree and organizational maturity as objective of sensitive processes
The meetings held to the joint ventures and the analysis of the documents allowed to the
project team to indicate the importance degree to be assigned to different processes types and
the level of organizational maturity "target".
In particular, the degree of significance means the importance assigned to specific processes
in the definition of an innovative management structure within the institutional and
regulatory framework that distinguishes the joint ventures that take the legal form. The scale
of the degree of relevance adopted is as follows:
- Low degree of importance: the process is governed by rules and regulations and
institutional regulatory system by default and is not susceptible to significant innovations;
- Medium degree of importance: the process presents some opportunities for innovation in
the management way and control by the joint enterprise;
- High degree of importance: the process is potentially manageable and controllable
according to innovative and original specifications of a single joint enterprise.
The degree of organizational maturity "target" instead is intended as the level of awareness
and accountability with which a specific process is considered should be maintained and
formalized within the corporate organization and management of trials (Burns et all 2002;
Rosenstack, 2002 , Cooke, 2004; Pennypacker, 2002, Cooke et all, 2002) ..
The presence of an appropriate level of organizational maturity is considered an important
mechanism to increase the capacity of regional system of regulatory control, of the ASL and
AGENAS. Indeed, the availability of systems, tools and procedures to be documented,
verified and standardized makes it possible to implement a no hierarchical control (expensive
and often subjective), but a check of compliance (Martinez, 2009). This solution, result of a
process of development and innovation, allows to preserve the differences of each
experimentation, that will decide to create the tools (mechanisms, bodies and procedures)
deemed most appropriate to their needs and specificity, but also to encourage a process of
evaluation by external actors called upon to verify the achievement of those results and
compliance with those standards already established themselves in the process of drafting the
implementation of the same experiment using an organizational model original.
The degree of organizational maturity goal was formalized and summarized by identifying
five levels of maturity, as distinct (Rosenstack, 2002; Pennypacker, 2002, Cooke et all,
2002).
Level 1-Performed: a process remains at this level when achieves its objectives through the
implementation of necessary activities. The existence of the process is detected only by the
presence of clear results.
Level 2 – Managed: a process remains at this level when it is planned, controlled and
modified by indicators measuring the results ex post.
Level 3 – Estabilished: a process remains at this level because his unrolling was formalized
and
standardized
in
specific
procedures
knowable
ex
ante.
Level 4 - Predictable: a process is maintained at this level when the measure of the
performance and the acquisition of information relating to its deviation from the standard
helps allows to make an estimates and forecasts on the future performance of the
organization.
Level 5 - Optimizing: a process is maintained at this level when you put in place measures
aimed to the improving to adapt it to new organizational needs.
It is important to note that the different situations observed are characterized by a high degree
of heterogeneity. Consequently, in each company the operations, the development efforts and
formalization of the various processes are carried out according to the time and priorities that
are often influenced by the history of experimentation, the partners' skills and the
institutional framework of reference.
However, depending on the preconditions and problems detected and identified as priorities
during the meetings, it is possible to estimate the degree of organizational maturity "target",
i.e. potentially deemed necessary for each job "type" trend inside the corporate structure and
organization of joint ventures in health care.
The degree of organizational maturity "target" assigned to each process is shown in Table 3,
presented below, it is the result of "combination" discussed and developed within the project
team of different perceptions and experiences in the experimentation, and also from the study
of business records and information that emerged from the interviews about how business
process execution and thus inevitably affected by the limits resulting from an effort of
synthesis and aggregation.
Such evidence should not be construed as an attempt to formulate an organizational model
"ideal" to be assigned to these experimentation. Instead, they constitute a useful reference
framework within which to place the organizational and managerial innovations specific to a
single joint enterprise.
Considerations are presented in the summary table below.
Tab. 1 Degree of organizational maturity
Process
Degree
Process of finalizing agreements with the High
regional health system
Process of evaluation and monitoring of health High
services accounted ASL
Level of
organizational
maturity
3 estabilished
3 estabilished
Process control and evaluation of the objectives High
of the contract
Assessment process and control of risk High
management
Process measurement and control of patient High
satisfaction, perceived quality
3 estabilished
5 optimizing
3 estabilished
Process of external communication
Medium
1 performed
Booking process
Medium
3 estabilished
Data collection of local health needs
Low
1 performed
Environmental Compliance Process
Low
3 estabilished
Selection process for managers
High
3 estabilished
Process evaluation and incentive system for High
managers
Process of staff planning, recruitment, staff High
training, incentives
Process of evaluation and monitoring of High
individual and incentive
5 optimizing
Process of evaluation
occupational safety
3 estabilished
and
control
of Low
5 optimizing
5 optimizing
Process of internal communication
Processo of total quality
Low
Medium
2 managed
4 predictable
Process and system of delegation and proxies
Medium
3 estabilished
Strategic Planning Process
Medium
3 estabilished
Process Budgeting
High
5 optimizing
Process of organizational change
High
4 predictable
Process of providing goods and services
Medium
4 predictable
Process of assessing and monitoring the Medium
investment
4 predictable
Process of managing ICT investments and new High
health technologies
5 optimizing
The basic hypothesis is that management innovation and organizational considered as an
essential precondition for giving life to an experiment may take various forms and may be
based on adoption of systems, procedures and other mechanisms. It is believed that the
mechanisms on which the concentrated effort of innovation, considered most relevant to
achieving the objectives of the experimentation, should be those with a greater level of
organizational maturity.
The originality and innovation of a specific organizational model adopted may be observed
as a function of each process and tools that in the companies have been geared to achieving a
degree of "maturity" considered appropriate respect to organizational objectives assigned to
experimentation.
This analysis has allowed to cover both the areas of greatest significance in terms of test
adopted and the presence or absence of potentially innovative organizational and business
models, as seen by contacts of the ASL, and Summit of Regions and the company
management.
4.4 Conclusions
The analysis conducted on the ten joint ventures revealed a high heterogeneity and also a
significant "wealth" in terms of experiences, results, management, technical and clinical
skills.
Project’s objective was not to reach an assessment of experimentation results observed. This
activity is the responsibility of regional administrations. Therefore, we do not highlight the
positive contributions that the various companies have made in the different contexts of
reference, since these results have also made official statements and documentary evidence in
both the institutional dialogue between society and government reference, and the existing
communications between the partners themselves (budgets, management reports,
management reports).
Instead the objective of the project was to facilitate a debate and the systematization of legal
and administrative system, which currently governs and influences the organizational and
managerial models that members and management of joint ventures may deem convenient or
develop.
It is believed that this analysis will provide a support role that AGENAS that has to play
against national and regional legislative bodies and policy makers the role assigned to publicprivate joint ventures in the national health system and the different regions.
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