Chapter 2

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for designing and governing organizational change within the different regional health systems. So, what is the state of the art, today, with respect to change? To which extent has organizational autonomy been exercised or is frustrated or encouraged at regional and national level? Which have been the key applications and the limits of a process of organizational development? Various analyses and research studies conducted in recent years confirm that the organizational element has been and remains both a cornerstone of and stumbling block for change. The next two paragraphs provide an overall picture of the principal areas of organizational innovation in the decade between 1996 and 2005, followed by several hypotheses for development, taking account of the risks and opportunities that have appeared on the scene in recent years. 3.4.2 Organizational innovation in 1996-2005 In a nutshell, the principal areas of organizational innovation carried out by health enterprises in the decade in question are: • the reorganization of hospitals into departments; Fig. 1 – The key areas of organizational innovation in local health enterprises (1996-2005) Hospital services Local services Staff functions Technical and administrative services Departments Hospital networks (both within a local health enterprises and between different health enterprises) Specialization and technological innovation Patient processes and management Health professions area Integration of hospitals and their local district Strengthening of the districts Management of the “district-department” matrix Organization of primary care Integration of health and social services Automation of care services systems Continuity of care Development of new functions in support of the management - management planning, programming and monitoring - marketing - finance - clinical engineering - staff training and assessment - organizational development - ………… Experimenting new management processes Automation and use of new technologies in the procedures Choice between centralization and decentralization Outsourcing Networks between different health enterprises Purchase centres [185] CEIS Health Report 2006
CEIS Health Report 2006 • the search for new organizational arrangements for the local services (solely for the ASLs); • the development of innovatory functions in support of management; • the rationalization of the technical and administrative support functions. For each of these areas, the following table contains an analysis of the principal organizational trends and the most widespread nationwide projects. 1. With regard to the first aspect, it is a fact that almost all the health enterprises have committed themselves, since the end of the 1990s, to reorganization along department lines, especially with respect to hospitals. The idea of reorganization into departments, which had already been envisaged by the Mariotti Reform of 1969, was taken up again in connection with the reorganization of the public health system along business lines, due to the potential advantages descending from the grouping together of the structures, not limited to increasing the integration of diagnosis and care processes (limited within the departments to specialist functional areas), but above all to the financial and organizational advantages descending from the possible economies of scale, pooling of resources, and streamlining of the decisionmaking processes. Currently, based on the more recent surveys, almost all hospitals, and most of the local health enterprises, have re-organized themselves into departments. This process has taken place according to different timescales, procedures and solutions, based on the grouping criteria of the operating units, the choice between functional or structural solution, with respect to the form of department, or the grouping of operating units within the same establishment (according to a “vertical” department model), or belonging to different establishments, according to the “horizontal” model. The reorganization of hospitals along department lines has been characterized, in recent years, by several criticalities and trends: a) first of all, a widespread tendency to view departments as a solution in itself, a sort of prerequisite, only to discover, over the years, that it is very hard to transfer the department-based structure into the organizational processes and cultures; hence, as widely highlighted by several research studies, the risk of defining the departments ‘only on paper’, without supporting their practical implementation with suitable design, implementation and organizational development processes, often hindered by staff opposition and the pre-existing organizational arrangements; b) a greater focus on the structural and regulatory aspects of the departments, but a lesser focus on building up the processes, resources and skills needed to implement them; hence, the widespread weakness of the department as a macrostructure capable of actually becoming, within the health enterprise, a strong and common point of reference, for both the bottom and the top, with respect to planning activities, managing resources and assessing results; c) the gradual shift, in the more recent applications, from functional departmental models – in which the Operating Units grouped together share common objectives but limited resources, and the Department Chief carries out coordination functions – to predominantly structural models, the prevailing aspect of which is the pooling of resources and [186]
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CEIS Health Report 2006 Management
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4.1.5 Structure of health expenditu
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strophic payments; moreover, the se
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● Doglia M, Spandonaro F, “Il p
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5.1 - The median age at death for m
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causes and the median age at genera
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in the South and Islands, not only
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5.2 - Analysis of avoidable deaths
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population of Italian citizens acco
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We wish to underline the mortality
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Diagram 4 - % composition of years
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among whites and blacks,1979-1989
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Figure 1 - Division % of the quota
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age dimension of enterprises (90 em
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BOX 2: National Medical Device Clas
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maceutiche in Italia (1997-2001)”
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5.4 - Mobility of italian patients
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Authority (ASL) will be charged for
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43.950.716,00. At this stage, if yo
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esting data are certainly provided
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have carried out economic and stati
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✔ DE POUVOURVILLE GÉRARD Researc
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✔ MENNINI FRANCESCO SAVERIO Degre
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✔ SCHWEIGER ARTURO Health Economi
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