SEEKING PERFORMANCE-BASED ACCOUNTABILITY IN ITALIAN PUBLIC HEALTHCARE ORGANIZATIONS.

AuthorRaucci, Domenico
  1. Introduction

    Reforms inspired by the New Public Management (NPM) principles have reshaped public sectors and, in particular, the healthcare sector (Andrews, Beynon and McDermott, 2019). The direct impact of the latter on the well-being of citizens together with vast public resources invested in it increased the attention of public healthcare organizations (PHOs) to performance management and accountability systems (Mattei et al., 2013; Anessi-Pessina and Cantu, 2016), framed in the public management literature (Pollit, 2018).

    In public organizations, those systems aim at supporting not only the internal managerial dimension, based on performance measurement, but also the external reporting processes (Fryer, Antony and Ogden, 2009). The close connection between the latter and public accountability is afflicted with the multifaceted meanings of transparency and accountability (Bovens, 2007), in particular in healthcare with its multiple stakeholders (Brinkerhoff, 2004; Ferlie, Montgomery and Pedersen, 2016). The traditional compliance-based accountability approaches, rooted in the formal compliance with regulations and the appropriateness of using public resources, evolved gradually towards PBA. 'Managing for results' requires manifesting effectiveness, efficiency and transparency in achieving results, which expresses the managerial autonomy attributed to public organizations (Borgonovi, Anessi-Pessina and Bianchi, 2018). In this framework, the PBA processes assume an effective operation of the underlying performance management systems, the adoption of which is the legacy of NPM reforms implemented in the public sector (Arnaboldi, Lapsley and Steccolini, 2015).

    In the Italian public sector, particularly relevant was the enactment of the Legislative Decree (L.D.) no. 150/2009 (hereafter, Decree), which, for the first time, enforced the introduction of the 'Performance Management Cycle' (PMC) and related PBA documents. This regulation affects all public organizations, including PHOs. Its transparency and PBA purposes are debated in the context of the effects of the NPM reforms and conditions necessary for NPM to 'work' in the public sector (Dan and Pollitt, 2015).

    From this perspective, studies on public healthcare conducted international comparative analyses on the intentional and unintended impacts of the reforms (Simonet, 2011), verifying the effects of combining multiple reforms in increasing efficiency, effectiveness and equity of healthcare services provision (Mattei et al., 2013) or examined specific impacts of new regulations in individual countries (Longo, Salvatore and Tasselli, 2011). Respecting the latter, research focused on the impulses of national legislation in the adoption of performance management systems and related PBA models in PHOs provided conflicting results (Jacobs, Marcon and Witt, 2004; Andrews, Beynon and McDermott, 2019). The moot point was the effectiveness of legislation-driven approaches in promoting those systems and in increasing transparency and PBA in healthcare organizations (Chang, 2006; Lehtonen, 2007).

    Studies that evaluated the impacts of the reforms on PHOs' results and outcomes generally agreed on the improvement in quality, efficiency and equity in the public healthcare services provision (Love, Revere and Black, 2008). In particular, higher openness and active participation of citizens in PBA increased patients' awareness of medical services available (Canaway et al., 2018), as well as triggered improvements in the PHOs' performance following the benchmarking logics (Bevan and Hood, 2006; Nuti, Vainieri and Bonini, 2010). Furthermore, increased transparency on PHOs' performance helped to prevent corruption, promoted broader organizational legitimacy (Curtin and Meijer, 2006; European Commission, 2013), and increased attention of national healthcare plans in rewarding quality and efficiency of these organizations (Ferlie, Montgomery and Pedersen, 2016). However, the same studies pointed out that greater openness to patients' assessments and data sharing resulted in PHOs providing ambiguous information or generating 'information noise' when complying with the transparency obligations (Bevan and Hood, 2006). This reluctance to develop a culture of transparency was also highlighted by Italian studies on the performance management and accountability systems adopted by PHOs, both of those implemented voluntarily or complying with sectoral regulations, with few studies (Mauro and Talarico, 2015; Bonollo and Zuccardi Merli, 2016) specifically investigating the PMC adoption pursuant to the Decree, and the contents of related PBA models.

    To fill the literature gap on PBA, our research of exploratory-descriptive nature aims to evaluate the adoption of the PMC in Italian LHAs, by exploring PBA contents produced during 2013-2018. Using content and cluster analyses, we verify the compliance level of the information presented in the PPs and the PRs with the accountability contents required by the Decree.

    To achieve this goal, in section 2 we review the literature on transparency, and PBA approaches in public organizations, in particular in LHAs. Sections 3 and 3.1 analyze the evolution of transparency measures in the Italian context. Section 4 presents the sample and the research method, while section 5 shows our results. The main conclusions are discussed in section 6.

  2. Transparency and PBA: an overview

    PBA purposes in public organizations are manifold since the concept of public accountability expresses the responsibility of these organizations for explaining and justifying their conduct towards stakeholders (Bovens, 2007). OECD (2001, p. 87) underlines that public organizations 'have an obligation to account for the use they make of citizens' inputs received, be it through feedback, public consultation or active participation'. To achieve their accountability purpose, these organizations 'need to ensure open and transparent decision-making processes amenable to external scrutiny and review'.

    These forms of openness are vital for public control, promoting greater accountability and answerability of public organizations (Borgonovi, Anessi-Pessina and Bianchi, 2018; Pollit, 2018). In particular, the principles of transparency constitute a prerequisite for PBA models and an impulse for organizations to focus on the role and effective functioning of the underlying performance management system (Hood and Heald, 2006; Fryer, Antony and Ogden, 2009). Moreover, technological advancement increases the timeliness of information and provides innovative ways to interface with public institutions, including the recent models of Open government and E-government (Holzer, Manoharan and Melitski, 2019). Higher levels of openness and interdependence of transparency with PBA processes can foster good governance practices (Osborne, 2010), stimulating organizations to efficiently use public resources and continuously improve their performance (Hood and Heald, 2006), also with incentives and sanctions (Brinkerhoff, 2004). A higher 'surveillance' on good governance practices promotes organizational legitimacy and prevents corruption (Curtin and Meijer, 2006). However, the literature does not agree on the impacts deriving from greater transparency compared to the purposes of the PBA (Hood and Heald, 2006). This is due to the complexity of performance measurement in public organizations, which makes concluding difficult (Hatry, 2002; Borgonovi, Anessi-Pessina and Bianchi, 2018), up to the risk of distorting organizational priorities and inhibiting innovation (Arnaboldi, Lapsley and Steccolini, 2015).

    In PHOs these problems escalate due to the absence of a market, personalization of services and related quality levels, clinical risk management, variety of outputs and unclear cause-effect relationships (Lega and Vendramini, 2008; Fryer, Antony and Ogden, 2009). Furthermore, the nature and purposes of accountability in PHOs is a challenge itself. The sector-specific literature interpreted this concept in several ways, primarily referring to the ability of organizations to 'give account' to patients, clinicians, health personnel, but also to satisfy public, political, and commercial health demands of communities (Brinkerhoff, 2004; Canaway et al., 2018). The wide range of audiences makes PHOs to focus more on easy-to-find and easy-to-understand information targeting the general public which mainly addresses the accountability type that Bovens (2007) defines as 'horizontal', whose nature complicates the links with performance measurements in these organizations. The complexity of the measurements mentioned above affects the effectiveness of PBA processes, comprehensibility of information by the public, and the stakeholders' trust (Love, Revere and Black, 2008; Halachmi and Holzer, 2010). Consequently, public organizations often used 'complexity' as an excuse for goal displacement and gaming, providing ambiguous information when complying with transparency obligations (Hatry, 2002; Ferlie, Montgomery and Pedersen, 2016). They hid relevant data in 'information noise' or 'information overload' or pursued the logic of 'blame-avoidance' on the results (Bevan and Hood, 2006).

    Literature also investigated the role of the legislative reforms inspired by the NPM in encouraging transparency within the framework called 'Freedom of Information Act' (FOIA). Many studies discussed conditions under which NPM legislative reforms 'could work' in the public sectors of different countries (Dan and Pollitt, 2015), including healthcare (Simonet, 2011; Mattei et al., 2013; Andrews, Beynon and McDermott, 2019). The research focused on the impulses of national legislation for building the transparency culture and on the effectiveness of legislation-driver in promoting performance management systems in public organizations delivered different results (Hood and Heald, 2006; Fryer, Antony and Ogden, 2009), also in the...

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