Chapter 2

3.4 - Strengthening the capacity
for organizational change in local health
enterprises
Tanese A. 1
3.4.1 Organizational autonomy: the state of the art
In the last ten years, the focus of change in health care facilities has been the size of the
organizations. Following the reorganization of the public health system along private business
lines, in fact, with the introduction of the so-called “aziende sanitarie”, i.e. local
health enterprises, which have been granted strategic and management autonomy, the
need has arisen to consider the “organization” variable as a lever for change.
The new ‘local health enterprises’ (ASL – Aziende Sanitarie Locali), unlike their predecessors,
the ‘local health units’ (USL – Unità Sanitarie Locali), are no longer mere local extensions
of the National Health Service (NHS) but independent establishments run according
to business criteria, albeit in partnership with the regional governments. The organizational
arrangement too requires the adoption of new more business-oriented planning and
implementation mindsets and tools. Therefore, each health enterprise has been given the
possibility (and, indeed, feels the need) to design and modify its macrostructure, to
“draw” its own organization chart, and to adapt its organizational structures and processes
according to its specific needs, without being required to implement a single goodfor-all
model and a set of predefined rules and functions.
So, what are the conceptual and operational implications of this organizational autonomy?
First of all, there is a move from an essentially legal and formal to a more instrumental
approach. The rationale of organizational decisions, in a business-oriented perspective,
cannot be based on the mere ex ante application of predefined and universally valid rules,
tenets and models, but on the continuous search for and implementation of organizational
solutions consistent with each health enterprise’s mission and strategic guidelines.
The General Manager, as the person responsible for running the enterprise, must constantly
adapt both strategy and structure, i.e. the goals and objectives he or she intends
to achieve with the establishment’s internal organization. The one aspect imposes constraints
on the other, but at the same time upholds it, in a highly interdependent relationship:
excessively ambitious objectives may not be sustainable by the organization,
but, at the same time, the capacity to innovate one’s organization may become a stepping
stone for and encourage strategic change and the achievement of higher levels of
performance.
1Administration Manager of the ASL Roma E, Professor of Business Organization and Marketing and of Change
Management at the Faculty of Social Sciences of the University of Chieti -Pescara.
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CEIS Health Report 2006