HRM practices and organizational change: Evidence from Italian clinical directorates

Abstract

Purpose

The healthcare sector has been facing major reforms, among which the introduction of the Clinical Directorate (CD) model for hospitals. The purpose of this work is to explore the degree of implementation of innovative Human Resource Management (HRM) practices within CDs, in order to understand whether, after more than 15 years from their introduction, they have been able to transform their managerial approach concretely, in line with the CD model’s objectives. The tools have been attributed to three main HR initiatives: training, control, and evaluation ones.

Design and methods

During on-site visits in 33 Italian hospitals, data were collected by conducting semi-structured interviews with their CEOs and Clinical Directors. Data concerned both the mere adoption of HRM tools within CDs, as well as their effective degree of implementation. The answers to the questions were translated into a system of percentage scores, so as to detect mean percentages of implementation in each CD.

Findings: The general degree of implementation of HRM practices is still somewhat distant from a theoretically excellent and full implementation, especially if we consider the important lag of time since the reforms affected the sector. Nevertheless, results open the way to important considerations about the effectiveness of the CD model.

Original value: The original methodology and scoring system suggested in this work produce a concise evaluation of the development of an effective HRM system within CDs. Our framework of analysis allows interesting benchmarking activities among different CDs of an organization and, ultimately, among different organizations. Moreover, the methodology presented may constitute a valid source of information in order to carry out future research on the items able to affect the implementation of such tools.

Keywords

clinical directorates hospitals HRM practices

Introduction

In order to meet the drastic pressures the Italian healthcare sector has been facing in the past 20 years,¹ a number of reforms have been introduced in the system, one of the most evident being the mandatory adoption of the Clinical Directorate (CD) model for all healthcare organizations operating on behalf of the public system.² This organizational model, coherent with the major organizational trends of the sector across Europe and the Western world, was introduced during the 1990s with the clear intent of pursuing greater efficiency without harming the quality of the healthcare services provided. However, although the model has been introduced in the system over 15 years ago, its concrete success is still widely debated.³

Indeed, a number of studies suggest that institutional and/or legislative changes are not sufficient to enact (or, at least, are not the sole determinants of) change in an organization’s identity. It is argued that such change requires a deep cultural one, able to overcome all those resistances that may hinder effective change. Indeed, one of the main assumptions in the population ecology perspective is that organizations face strong internal inertial forces that hinder their attempts to adapt to environmental change.^4,5 Overcoming factors such as a lack of capacity of action and the presence of consolidated routines, therefore, seems to be the only way to enhance fully implemented CDs.^3,6,7

This work wants to spread light on to the still poorly explored issue about whether CDs have really fostered change in line with their objectives. To do this we explored the extent of adoption and actual implementation of Human Resource Management (HRM) practices in CDs, by using an innovative framework of analysis. We suggest an analysis of such implementation cannot be disregarded in the attempt to understand the concrete phenomenon of changing organizations. As mentioned, without changing the way people work and behave, a mere re-shaping of organizational structures risks remaining a sterile attempt to pursue innovation without dealing with decoupling phenomena. In summary the study wants to provide an answer to the unsolved matter of whether the CD organizational model has concretely produced changes in HRM approaches, bringing them in line with the model’s theoretical objectives.

Theoretical background

A number of studies have shown how organizational transformation has often failed because of inabilities to face a limited motivation to change among health professionals.⁸ Structural changes may not be accompanied by cultural ones and may create misalignments between leadership goals and workforce goals. It is not at all obvious that employees should share the same understandings^9,10 or feelings¹¹ as their managers toward change.

The issue of employees’ motivation or commitment to change has been articulated in concepts such as readiness for change,¹² openness,^13,14 positive coping,¹⁵ change-related cynicism or resistance.¹⁶ Metselaar defines willingness to change as “a positive behavioral intention towards the implementation of modifications in an organization’s structure, or work and administrative processes, resulting in efforts from the organization member’s side to support or enhance the change process”.¹⁷ Its absence may be due to misaligned incentives for adoption, un-sustained leadership, lack of support and/or training, competing priorities.^18,19

What, however, seems to be a common conclusion of most studies is that the support of employees is crucial for the successful implementation of organizational change.^10,20 And indeed some studies put in doubt the concrete possibility of transforming healthcare organizations into non-bureaucratic institutions by implementing “managerial approaches”. For example, Anderson and McDaniel²¹ argue that health care organizations are both professional organizations and complex adaptive systems and must seek an integration of these two intricate features. The leadership tasks required to do so, however, appear complex and exceptionally “unusual”, denoting deep challenges in the concrete overcoming of bureaucratic stereotypes.

Achieving concrete change, therefore, seems to be one of the most difficult challenges management can face. The risk is to incur into the so-called decoupling phenomenon, which consists in the adoption and the contextual non-implementation of organizational models.^22–25

Therefore, the mere design of new organizational models cannot leave aside the issue of actually managing the implementation of change through, for example, the adoption of new processes, mechanisms, and managerial tools.²⁶ Reforms in the public sector have too often overlooked such issues and made little impact on the products and services provided, or the impact they have made has been quite different from what was intended.^27–30

This seems particularly true in the health care sector, in which if not well performed, organizational change can result in losses in organizations’ resources, negatively impact the quality of care patients receive and, ultimately put at stake organizations’ actual survival.³¹ As Brunsson puts it, hospitals are “arenas”³²: members of these external groupings learn how to rationalize the rules they represent, but their rationalizations are based on general, political, partisan, or professional objectives rather than on local, organizational ones.³³ For instance, values about being economical or even efficient seldom loom large among the professionals, which can easily mean that what managers regard as good results and what professionals strive to achieve are by no means the same thing.³⁴ For an “arena” to become a more complete organization, it therefore needs goals for the organization as such rather than general external objectives, and a local management responsible for achieving organizational results.³²

In other words, an organization’s functioning depends on the actions of its members and it can change only when members’ behavior changes.³⁵ An important leverage to affect human resources’ behaviors seems to be associated to HR practices^36,37 which can considerably shape the behavioral aspects of change,³⁸ engaging employees in change efforts, building commitment and thereby enhancing the organizations capability to change.³⁹ Indeed, previous research agrees upon the positive effects of HR practices on employees’ attitudes and contribution to enhanced firm performance,^40–42 especially if the management does not fail in clearly communicating the organization’s vision, by carefully designing change initiatives in coherence with the organization’s strategy.^39,43,44 In this vein, it appears crucial to quantify the degree of coherence and pervasiveness of HRM tools within a health care organization, in line with the major transformations new organizational models have implied.

From a local to an international context

The context of the present study is represented by the Italian National Health Service (I-NHS) which, just as the British NHS, provides universal coverage and is responsible for the delivery of healthcare services and programs to all its citizens. During the 1990s, the Italian NHS faced strong reforms in an era in which several public-service reforms have aimed at “letting managers manage” or at “freeing managers to manage”.^45,46 The main transformations introduced through such reforms included:

the delegation of responsibilities from the central State level to the Regional level in reference to managerial accounting, financial and organizational matters;

the deep change in healthcare organizations’ “identity”, with a switch from typically public bureaucratic organizations to entities that, just as private ones, are directly accountable for the quality of the services offered as well as the degree of efficiency reached in doing so;

the rise of competition between (both public and private) organizations and the possibility for people to freely choose where to receive assistance.

These changes highly internalized the main principles of the so-called New Public Management (NPM), which had transformed starkly the healthcare scenario across Europe and in the Western world and which is aimed at making the public service more “businesslike,” by improving its efficiency and by using private sector management models.^47,48

The application of NPM principles to the healthcare sector has implied the adoption of the Clinical Directorate (CD) model within health care organizations. This organizational model, introduced at first in the United States during the 1980s, quickly became the most frequent response European healthcare systems provided to the new managerial challenges the NPM approach implied, being considered the most suitable to balance the need for greater efficiency with quality improvement.³ CDs are semiautonomous hospital divisional units in which several clinical wards are integrated or merged.^49,50 Although wards may be aggregated on the basis of different criteria, the main intent of the law is clearly to assign responsibility to organizations by creating subunits that are accountable for their own activities. The CD model has important managerial implications. Clinical Directors cover an intermediate managerial role between top management on one side and clinical wards on the other. Top management can now focus on setting strategic results and measuring their achievement, while delegating coordination and operational control activities to CDs.⁵¹ What emerges, therefore, are new organizations with nonbureaucratic features and a decentralized decision-making asset, which is combined to the historical professional autonomy typically found in health care organizations.

Organic philosophies, therefore, seem to be a lot more appropriate and coherent with the delegation of responsibilities to CDs. Consequently, it is clear that clinical directorates (and Directors) assume a fundamental role in the implementation of change. Indeed, the pivotal role of the middle management in times of reforms has often been documented.^52,53 In particular the task of middle managers is to translate formal and administrative rules into practical activities, coordinating the group and managing emerging conflicts. According to Podsakoff and colleagues,⁵⁴ the “leaders of change”, in this case represented by Clinical Directors, need to articulate its vision, collect the efforts to drive the acceptance of the group, and provide employees’ intellectual stimulation. In other words, middle managers must be able to affect employees’ supportive behavior toward change.^55,56 Their actions are thus finalized not just at influencing the adoption of change, but specially at driving its correct implementation, by adopting those necessary processes, mechanisms and managerial tools mentioned above.²⁶

Nevertheless, the effectiveness of the ability to implement change in CDs has still been poorly explored. The approach suggested in this work consists in analyzing the adoption and the degree of concrete implementation of relevant HRM practices in CDs, holding on the assumption that in order to change organizations, it is necessary to change how people work and, therefore, the way of managing them.

Literature recognizes four main initiatives regarding management of human resources. These are: (a) human resources’ selection and hiring; (b) training and retention; (c) evaluation; (d) layoff.⁵⁷ However, in the Italian public healthcare system, as is often within the public systems in general, phases such as hiring and layoff are strongly regulated and leave little flexibility to managerial subjectivity. On the contrary, training and evaluation activities see a high managerial autonomy admitted by the law. It seems reasonable, therefore, to focus studies on managers’ impact on HRM solutions on these two phases. In particular, training and retention tools have to do with fostering professional growth in terms of knowledge, skills and organizational behaviors in order to uniform problem solving approaches within CDs⁵⁸; evaluation tools must aim at assuring that the goals set are concretely achieved by people and teams. Specifically, this latter category can assume two different configurations: the first has indeed to do with controlling the correct implementation of processes and procedures (due to the difficulty of measuring outputs and outcomes of healthcare processes, it is necessary to standardize them in order to reduce variability of results); the second has to do with a management-by-objectives perspective (i.e. the recognition of benefits and economic incentives related to the achievement of preconceived objectives and goals).⁵⁷ From here we derived the three groups of initiatives, which have been designed in coherence with those studies suggesting the presence, within the public sector, of some strategic HR practices able to generate a high commitment of employees toward their organization. In particular, our approach consists in a re-elaboration of previous grouping efforts of HRM practices into similar groups.^53,59

In brief, it seems to be still unknown to what extent, after around 15 years from their introduction in the system, CDs have been able to innovate their HRM system, in coherence with its objectives. In other words, the authors hold on the assumption that scenarios characterized by innovative and lively HRM systems have most likely been able to truly implement the model, avoiding the presence of decoupling phenomena and overcoming barriers and people’s resistances to change. In this vein, this exploratory study investigates the extent to which HRM practices have permeated clinical directorates and their daily functioning in Italy, which may be considered an emblematic setting of the European context.

Materials and methods

Our sample is composed of 65 CDs, belonging to 33 Italian health care organizations. The latter were selected by the Italian Ministry of Health (IMH) on the basis of their relevance and representativeness of the different geographical location and institutional typologies of healthcare organizations.⁶⁰ Indeed, 45% of the sample was located in Northern Italian regions, 31% in Central ones, 24% in Southern Italy. Moreover, 24% of the sample was made up of local health units, 31% of hospital trusts, 37% of university hospitals, 8% of research hospitals. Such sample, although necessarily limited in size in order to carry out an in-depth study, reflects clearly the national scenario in so far it catches all the different institutional typologies of public healthcare organizations throughout the whole country. Indeed, previous studies, with larger representative samples, tend to confirm the percentage distributions among institutional typologies and geographical locations detecting, for example, the presence of more organizations in the North, if compared to Central and Southern Italy.³ Each healthcare organization autonomously selected two CDs (with the exception of one organization, which selected only one CD) to be involved in the study.

Our data were gathered through a national survey funded by the IMH. The original project had a broader research scope than the work reported in this paper. The focus was a profound analysis of the CD model. The original questionnaire was built upon a list of over 100 items identified by our research group and by the team work of the IMH, which were felt to be expressive of the typical organizational features of CDs.^a Such items were selected following literature reviews carried out on the topic as well as notions gathered from the researchers’ on site experience in the healthcare sector. During on-site visits we collected data by conducting semi-structured interviews with health care organizations’ CEOs and Clinical Directors, who were viewed as the key figures to interview in order to achieve an exhaustive picture of CDs’ characteristics. All interviews were preceded by a meeting with the Clinical Director of each directorate and some representatives of the Department Committee, with the aim of illustrating the overall objectives of the research. Additional information regarding the structure of the CDs (e.g. number and type of ward units merged into directorates, number of staffed beds) was assessed through a database managed by the IMH.

Out of the original 100 items, 50 were selected for the present research,^a since they focused on the implementation of HRM practices within CDs. In particular, we focused on the presence and concrete degree of application of the three different kinds of HR managerial practices mentioned:⁵⁷ training-related, control-related and objectives-related tools.

In order to measure the implementation of these three dimensions, we divided the 50 selected questions into the three HRM practices’ groups, on the basis of their pertinence to each category of HRM practices. In particular, for each category we explored both the mere presence or absence of specific practices within the CDs, as well as their concrete degree of implementation. To do so, questions not only measured statements about the “adoption” of a practice, but rather further explored their implementation through dimensions such as, for example, the frequency with which specific activities are carried out or the number of people involved in them. An example referred to an objectives-related tool can clarify the approach:

Question A277: Do you apply financial and/or non-financial incentives to the degree to which the clinical directorate’s objectives are concretely reached? No □ Yes (please specify type of incentive) □

Question A278: If present, to what sort of objectives are these incentives related? Assistance □ Research activities □ Teaching activities □ Containment of costs □ Other (please specify) □

The translation of results into scores was then carried out by assigning a maximum theoretical absolute value to each question, translating it then into a percentage score. Following from the same example:

Question A277: Answers No=0; Answers yes=1 (absolute score)

Answers No=0%; Answers yes=100% (percentage score)

Question A278: No item is selected or mentioned=0; 1 item=1; 2 items=2; … n items=n (absolute score)

No item is selected or mentioned=0%; 1 item=1/n%; 2 items=2/n%; … n items=100% (percentage score)

In Table 1 we present the main contents at the basis of the questions ascribable to the three HRM practices’ families, as well as the percentage scores of implementation they reach within the sample (being often more than one item ascribable to such contents, the score indicated is the average one).

Table 1.

Contents of training-, control-, and objectives -related HRM tools, and percentage score of implementation.

Training-related tools	Score (%)	Control-related tools	Score (%)	Objectives-related tools	Score (%)
Training through practical experience (learning by doing)	87	Reports and documentation at CD level	89	Evaluation by objectives	92
Training Programs provided at CD level	84	Pathways at CD level	83	Formulation of objectives at CD level	73
Coherence training/strategic inputs	47	Clinical Audit	69	Compensation by objectives	47
Employee training database	46	Organizational rules at CD level	51	Autonomy in defining strategies	46
		New professional figures and roles	51	Projects at CD level	27
		Certifications	15

By translating the answers to the questions into a system of percentage scores, we detected a mean percentage of implementation (with respect to a theoretical 100% implementation) in each CD of the sample, for each of the three families. We then performed three pairwise correlation analyses between the scores of couples of HRM families, in order to understand whether there exists a tendency to privilege one or more families of practices at the expense of the others or whether, on the contrary, the tendency is to invest in each simultaneously.

Results

In order to investigate the degree to which Italian CDs have concretely implemented the “ideal set” of HRM practices within their daily activities, the scores reached in each of the three HR initiatives are illustrated in Figures 1 to 3.

Figure 1.

Clinical directorates’ score in the implementation of training-related HRM tools.

Figure 2.

Clinical directorates’ score in the implementation of control-related HRM tools.

Figure 3.

Clinical directorates’ score in the implementation of objectives-related HRM tools.

In reference to training-related HRM tools, we observe a mean implementation value of 68% of the theoretical maximum implementation, with scores ranging from 14% to, in eight cases, 100%. The value drops to 62% both for the control-related and the objectives-related tools, with scores ranging from 32% to 91% in the first case, and from 10% to nearly 90% in the second case.

Both HRM initiatives related to the evaluation phase are less implemented than training tools. This point produces interesting food for thought. Indeed, the fact that there exists a gap between these two dimensions may suggest that some of the efforts made in training staff do not completely correspond to equal efforts in detecting their results and effects. This can potentially lead to important areas of waste, whereas the translation of training efforts into “concrete results” is not fully developed. Nevertheless, the entity of this gap does not appear particularly wide, suggesting perhaps the desirability of monitoring the evolution of this phenomenon in time, without however detecting in this phase a dramatic unbalance between the two. Interestingly, though, although each of the three scenarios presents a very wide variability in results, only in the training asset do we find examples of a full implementation of the set of tools available throughout the sector.

In Table 2, we further present the percentage scores of implementation of HRM tools by geographical location and institutional typology of the healthcare organizations belonging to the sample.

Table 2.

Percentage scores of implementation of HRM tools by geographical location and institutional typology.

	Training-related tools	Control-related tools	Objectives-related tools
North	75.0%	62.0%	43.1%
Center	68.2%	58.8%	47.2%
South	62.6%	48.8%	45.5%
LHU	73.0%	67.2%	52.1%
Hospital trust	69.8%	50.0%	40.6%
Teaching hospital	69.5%	57.2%	44.3%
Research hospital	61.8%	62.2%	42.6%

Finally, to test the relationships between the implementation strategies of the three families of practices, Table 3 reports the outcomes of the pairwise correlations performed.

Table 3.

Pairwise correlations among the three set of tools.

			Control	Training	Objectives
Spearman’s rho	Control	Correlation Coeffic.Sig. (two-tailed)N	1.000.65	0.491^a0.00065	0.577^a0.00065
	Training	Correlation Coeffic.Sig. (two-tailed)N	0.491^a0.00065	1.000.65	0.435^a0.00065
	Objectives	Correlation Coeffic.Sig. (two-tailed)N	0.577^a0.00065	0.435^a0.00065	1.000.65

^aCorrelation is significant at the 0.01 level (two-tailed).

The analysis of coefficients reveals a positive association between each pair of dimension. In particular, there exists a positive and significant correlation between the implementation of training-related tools and of control-related ones (ρ = 0.49, p = 0.000) as well as between training-related and objectives-related ones (ρ = 0.44, p-value = 0.000). Finally, the trend is confirmed by the positive and significant correlation between the adoption of control-related and objectives-related tools (ρ = 0.58, p-value = 0.000).

The positive correlations among couples of sets of practices suggest that they tend to be developed in parallel. The fact that there emerges no tendency to adopt one set of practices at the expense of the others, might mean that there may exist some favorable scenarios that globally encourage the development and implementation of innovative HRM practices in general. Literature seems to support this thesis.^61,62 Indeed, if this is the case, it would seem that such scenarios can make a determinant difference, considering the very strong variability of scores reached by different CDs. Moreover, it seems reasonable that the strongest correlation is indeed between control- and objectives-related tools, suggesting that where one does invest in the evaluation phase, such investment is likely to cover both of its main components.

Discussion and future developments

The approach of this study clearly is aimed at detecting the “infiltration level” of HRM tools in CDs, in order to assess the degree to which they have concretely directed people’s behaviors towards the objectives the organizational model entails. The potentiality of this approach consists exactly in providing policy makers and top management with a correct vision of the tangible responsiveness of health care organizations to the CD model. Such responsiveness, as explained, is in good part held to depend on the impact middle management (Clinical Directors) may exert on the daily functioning of working activities through the introduction of an innovative and business-like HRM approach.

The first point of interest has to do with a mean score of implementation superior to 60% of a theoretical maximum for each of the three areas analyzed. It is worthwhile to comment this percentage, trying to establish whether it is to be considered satisfactory or not. The authors’ interpretation here is that clearly there still is a lot to do in order to reach an ideal implementation of HRM practices at the CD level. Nevertheless we would be cautious in labeling these results as unsatisfactory as previous studies have done³ for two orders of reasons. The first has to do with the physiological distance there exists between ideality and feasibility. Although we defend our conceptual framework, we are aware that contingent factors make it impossible, or at least very unlikely, to develop the “full set of practices” HRM provides. Indeed, some of these might be inapplicable (e.g. because of the size of the organization, or of its mission) or might even be incoherent with the organization’s (and CD’s) strategy.

The second reason why this percentage might be considered satisfactory has to do with the consideration that CDs did not exist before the reforms of the 1990s.⁶⁰ Of course nearly two decades have passed since their introduction and their effects should be reached by now, nevertheless forms of structured decentralization were very poor till the introduction of CDs.⁶³ This means that the shift to a managerial, decentralized approach has had to start from scratch. In turn, this induces to believe that what is indeed observable in terms of degree of implementation is totally ascribable to the effects of the model, suggesting a definitely large impact on organizations’ features.

As mentioned, the study detected a high variability in the percentage scores reached, with ranges covering over 80 percentage points. This great variability suggests that there exist very different scenarios throughout CDs. Future research should explore which technical features (for example, in reference to organizations’ institutional typologies, size, geographical location) and which characteristics of top and middle management (e.g. leadership styles both within the Region, organization and CD) are likely to stimulate more favorable environments to an effective implementation of the organizational model. Indeed, as noted previously, the fact that each of the three pairwise-correlations performed resulted positive and significant, suggests that there might indeed exist factors that positively affect such implementation as a whole. In other words, we did not detect strategies aimed at investing primarily in one of the three areas, but rather there seem to exist more “favorable CDs” in which all three dimensions are likely to be developed conjunctly. Nevertheless, the aforementioned fact that there seems to be a gap between the implementation of training tools on one side and of evaluation ones on the other, should stimulate a reflection on the reasons that have led to this discrepancy and to its possible effects. The first could have to do with a historical lack of “evaluation culture” gathered in long decades of scarce accountability of Italian health care organizations, due to the highly bureaucratized environment they were part of. If this is the case, after nearly two decades from the introduction of the CD model, we might still be paying for this lack through a lag in the development of evaluation tools. The effects of this discrepancy, on the other hand, appear potentially harmful, especially in the eventuality in which the dimension of such discrepancy is not kept under control in time. Indeed, the risk is to incur into forms of waste whenever investments in training do not generate corresponding improvements in performance. These, in turn, risk not being fully detected in the absence of a well-designed evaluation system. It is also interesting to note that if training activities are not directly tied to employees’ educational needs as detected by evaluation initiatives, the risk is to incur into an ungrounded training program.

Finally, it is worthwhile mentioning some limits of this study: a limit may have to do with the criterion adopted in the selection of the sample of CDs. As mentioned, the CDs have been chosen autonomously by their organization. This may have implied the tendency to select the “best” CDs in terms of organizational innovation and effectiveness. Although this may create a bias in our results by detecting a somewhat higher percentage of HRM tool implementation than what could be found in the population of Italian CDs, this effect shall be mitigated in future research by extending the sample and, anyhow, is not perceived to have any effect on the relative values of implementation among families.

A further limit of the study could be given by the awareness that HRM tools are for sure not the only form of implementation of the CD model. In order to assess the effectiveness of the model, therefore, it is first necessary to analyze other dimensions, such as managerial accountability strategies, development of processes, etc. Therefore, it is important to be aware that future forms of generalizability of our results should be accompanied by considerations on how these other dimensions are dealt with in CDs. Still the authors believe, in coherence with both the literature described in this work and with evidence emerging from on-site experience, that HRM practices constitute a fundamental enabler of organizational change, which have extremely deep effects on the ability of overcoming decoupling phenomena.

Finally, it may be argued that a part of the HRM tools analyzed may not necessarily be connected to the implementation of the new organizational model. Some might have been implemented before the transition took place, since indeed some form of HRM must have always been carried out. Nevertheless, the authors of this work maintain the position that such possible limitation does not affect the overall findings of the study. In the first place, the tools explored are typical of those managerial approaches that have characterized Italian healthcare organizations after the major reforms of the sector and exactly their absence has encouraged the introduction of the reforms. Moreover, and most importantly, the detection of the implementation of tools is conducted at the CD level. This means that we have captured the degree of autonomy as well as of innovation of CDs. In other words, the more we detect the implementation of tools at the CD level, the more CDs are autonomous and accountable of their HRM, attesting therefore a higher commitment to the organizational model. The approach adopted, indeed, captures both the degree of autonomy reached by CDs and the ways in which such autonomy is used to implement the model and, hence, achieve the directorates’ objectives.

Further steps of this study should extend the sample analyzed in order to safely generalize any conclusion. In particular, due to the similar characteristics among European NHS systems, it would be interesting to apply the methodology across countries in order to extend conclusions on how different geo-political scenarios may affect change. Moreover, future studies are highly recommended to explore enabling and obstructive factors to HRM tools’ implementation, in order to provide tangible hints and recommendations to health care organizations’ middle management. For example, implications could be produced in terms of the ideal size and complexity of CDs.

Practice implications

The methodology and scoring system suggested in this work produce a concise evaluation of the development of an HRM system within CDs. Positioning CDs within a “theoretical maximum score” allows interesting benchmarking activities among different CDs of an organization and, ultimately, among different organizations. This activity can lead to tangible conclusions, given the impressive distance there seems to exist among CDs. In particular, trying to understand what environmental, organizational, cultural differences emerge between CDs with a high and low positioning can represent a key approach in trying to decode barriers and enablers of change.

The methodology and scoring system suggested in this work can produce practical guidance at the central (regional), organizational and CD levels. In the first case it does so by providing a clear and concise picture of the model’s concrete effects on the adoption of HRM tools, stimulating reflections on its real extent of infiltration within the healthcare sector. Policy makers should be aware of these scenarios in order to assess the success of past strategies and better formulate future ones.

At the organizational level, the information provided by this sort of analysis produces precious insights on the responsiveness of the organization not only to external normative pressures, but also to pressures deriving from internal and external stakeholders (internal staff, professional registers, etc.). Being in possess of a clear awareness of an organization’s degree of managerial innovation allows its top management to better define objectives and set priorities, as well as to provide a grounded assessment of the gap existing between strategy and “real life”. An interesting potential can also be detected in terms of possible benchmarking activities between organizations.

Results suggest that healthcare managers should pay attention to the development of HRM practices, given that a strong relationship between HR practices seems to exist. A clear example comes from training and evaluation tools. For an effective management to take place, it is necessary to base training activities on the gaps evidenced by the evaluation system. Moreover, the evaluation system should take in account both results relative to an increase in terms of skills and competencies following specific training activities, and the impact of those training activities on general performance. Healthcare managers are recommended to develop contextually training and evaluation systems if they want to guarantee the right motivation and knowledge to their employees. Finally, at the CD level, this tool can provide practical guidance to Clinical Directors on the effectiveness of their managerial approach. Again, benchmarking activities can be carried out both within and across organizations.

Finally, it is perhaps worth mentioning that the present theoretical framework and scoring system may be highly useful in the attempt to produce research aimed at explaining which factors may favor or hinder a full implementation of those HRM tools held to empower healthcare organizations to truly foster the new organizational model.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

References

Vasselli

Filippetti

Spizzichino

Misurare la performance del sistema sanitario. Proposta di una metodologia. [Measuring the performance of National Health Service. Proposal of a methodology]. Il Pensiero Scientifico Editore, Roma, Italy, 2009.

Mascia

Morandi

Cicchetti

Hospital restructuring and physician job satisfaction: An empirical study. Health Policy 2014; 114: 118–127.

Mascia

Morandi

Cicchetti

Looking good or doing better? Patterns of decoupling in the implementation of Clinical Directorates. Health Care Manage Rev 2013; 39: 111–123.

Hannan

Freeman

The population ecology of organizations. Am J Sociol 1977; 82: 929–964.

Hannan

Freeman

Structural inertia and organizational change. Am Sociol Rev 1984; 49: 149–164.

Braithwaite

Westbrook

Hindle

et al. , Hospital sector organizational restructuring: evidence of its futility. In: McKee L, Ferlie E and Hyde P (eds) Organizing and reorganizing: power and change in health care organizations. Basingstoke, UK: Palgrave Macmillan, 2008, pp.33-45.

Mcnulty

Ferlie

Process transformation: limitations to radical organizational change within public service organizations. Organiz Studies 2004; 25: 1389–1412.

Goes

Achieving organizational change in health care through people and culture: a commentary. In: Jason AW, Heather H, Mark JM, Len F and Grant TS (eds) Advances in health care management. 2011, Vol. 10, pp.117–121.

Balogun

Johnson

Organizational restructuring and middle manager sense-making. Acad Manage J 2004; 47: 523–549.

10.

Bartunek

Rousseau

Rudolph

et al . On the receiving end: sense-making, emotion, and assessment of an organizational change initiated by others. J Appl Behav Sci 2006; 42: 182–206.

11.

George

Jones

Towards a process model of individual change in organizations. Human Relat 2001; 54: 419–444.

12.

Armenakis

Harri

Field

Making change permanent: a model for institutionalizing change interventions. In: Pasmore

Woodman

(eds) Research in organizational change and development. 12. ed. Stamford, CT: JAI Press, 1999, pp.97–128.

13.

Lines

Influence of participation in strategic change: resistance, organizational commitment and change goal achievement. J Change Manage 2004; 4: 193–215.

14.

Wanberg

Banas

Predictors and outcomes of openness to changes in a reorganizing workplace. J Appl Psychol 2000; 85: 132–142.

15.

Judge

Thoresen

Pucik

et al . Managerial coping with organizational change: a dispositional perspective. J Appl Psychol 1999; 84: 107–122.

16.

Stanley

Meyer

Topolnytsky

Employee cynicism and resistance to organizational change. J Business Psychol 2005; 19: 429–459.

17.

Metselaar

Assessing the willingness to change: construction and validation of the DINAMO. PhD Thesis, Free University of Amsterdam, The Netherlands, 1997.

18.

Alexander

Hearld

The science of quality improvement implementation: developing capacity to make

a difference. Med Care 2011; 49: S6–S20.

19.

Nembhard

Alexander

Hoff

et al . Why does the quality of health care continue to lag? Insights from management research. Acad Manage Perspect 2009; 23: 24–42.

20.

Herold

Fedor

Caldwell

Beyond change management: a multilevel investigation of contextual and personal influences on employees’ commitment to change. J Appl Psychol 2007; 92: 942–951.

21.

Anderson

Mcdaniel

Managing health care organizations: where professionalism meets complexity science. Health Care Manage Rev 2000; 25: 83–92.

22.

Meyer

Rowan

Institutionalize organizations: formal structure as myth and ceremony. Am J Sociol 1977; 83: 340–363.

23.

Hallett

Ventresca

How institutions form: loose coupling as mechanism in Gouldner’s patterns of industrial bureaucracy. Am Behav Sci 2006; 49: 908–924.

24.

Westphal

Zajac

Decoupling policy from practice: the case of stock repurchase programs. Admin Sci Quarter 2001; 46: 202–228.

25.

Morandi

Managerial solutions to hospitals’ challenges. Hauppauge, NY: Nova Science Publishers, 2016.

26.

Collis

Montgomery

Corporate strategy. Milan, Italy: McGraw Hill, 1998.

27.

Pressman

Wildavsky

Implementation. Berkeley, CA: University of California Press, 1973.

28.

Brunsson

Olsen

The reforming organization. 2nd ed. Bergen: Fagbokforlaget, 1997.

29.

Taylor

Groene

European hospital managers’ perceptions of patient-centred care. A qualitative study on implementation.

J Health Organiz Manage 2015; 29: 711–728.

30.

Willis

Saul

Bevan

et al . Sustaining organizational culture change in health systems. J Health Organiz Manage 2016; 30: 2–30.

31.

Jacobs

Weiner

Reeve

et al . Determining the predictors of innovation implementation in healthcare: a quantitative analysis of implementation effectiveness. BMC Health Serv Res 2015; 15: 6.

32.

Brunsson

Reform as routine. Organizational change and stability in the modern world. Oxford, UK: Oxford University Press, 2009, pp.51–55.

33.

Abbott

The systems of professions. An essay on division of expert labor. Chicago, IL: The University of Chicago Press, 1988.

34.

Abernethy

Stoelwinder

The role of professional control in the management of complex organizations. Account Organiz Soc 1995; 20: 1–17.

35.

Goodman

Dean

JW.

Creating long-term organizational change. In: Goodman PS (ed) Change in communication. San Francisco: Jossey-Bass, 1982, pp.226–279.

36.

Ellis

The benefits of partnership for OD and HR: the changing roles of OD and HR create a new partnership dynamic. Strategic HR Rev 2007; 6: 32–35.

37.

Mossholder

Richardson

Settoon

RP.

Human resource systems and helping in organizations: a relational Richardson perspective. Acad Manage Rev 2011; 36: 33–52.

38.

Barratt-Pugh

Bahn

Gakere

Managers as change agents: implications for human resource managers engaging with culture change. J Organiz Change Manage 2013; 26: 748–764.

39.

Ogilvie

Stork

Starting the HR and change conversation with history. J Organiz Change Manage 2003; 16: 254–271.

40.

Pfeffer

Competitive advantage through people: unleashing the power of the work force. Boston, MA: Harvard Business School Press, 1994.

41.

Pfeffer

The human equation: building profits by putting people first. Boston, MA: Harvard Business School Press, 1998.

42.

Huselid

MA.

The impact of human resource management practices on turnover, productivity, and corporate financial performance. AMJ 1995; 38: 635–672.

43.

Ulrich

Brockbank

The HR value proposition. Boston, MA: Harvard Business School Press, 2005.

44.

Brisson-Banks

Managing change and transitions: a comparison of different models and their commonalities. Library Manage 2010; 31: 241–252.

45.

OECD. Governance in Transition: Public Management reforms in OECD Countries. Paris, France: OECD, 1995.

46.

Schick

The spirit of reform: managing the New Zealand State Sector in a time of change. A report prepared for the State Services Commission and the Treasury, New Zealand, 1996.

47.

Hood

The “New Public Management” in the 1980s: variation on a theme. Account Organiz Soc 1995; 20: 93–190.

48.

Christensen

Lagreid

Transcending the new public management. The transformation of public sector reforms. New York, USA: Ashgate Publishing, 2007.

49.

Lega

The rise and fall(acy) of clinical directorates in Italy. Health Policy 2008; 85: 252–262.

50.

Braithwaite

Westbrook

Hindle

et al . Does restructuring hospitals result in greater efficiency? An empirical test using diachronic data. Health Serv Manage Res 2006; 19: 1–12.

51.

Fontana

“Dipartimenti e governo clinico in una prospettiva organizzativa e gestionale”. In: A. Cicchetti, I dipartimenti ospedalieri nel Servizio Sanitario Nazionale. Origini, evoluzioni e prospettive. Franco Angeli, Milan, Italy, 2012.

52.

Harding

Lee

Ford

Who is the “middle manager”?

Hum Relat 2014; 67: 1213–1237.

53.

Giauque

Attitudes toward organizational change among public middle managers. Public Personnel Manage 2015; 44: 70–98.

54.

Podsakoff

Mackenzie

Moorman

et al . Transformational leader behaviors and their effects on followers’ trust in leader, satisfaction and organizational citizens behaviors. Leadership Quarter 1990; 1: 107–142.

55.

Herscovitch

Meyer

Commitment to organizational change: extension of a three component model. J Appl Psychol 2002; 92: 942–951.

56.

Abrell-Vogel

Rowold

Leaders’ commitment to change and the effectiveness in change- a multilevel investigation. J Organiz Change Manage 2014; 27: 900–921.

57.

Costa

Gianecchini

Risorse umane, persone, relazioni e valori. Milano, Italy: McGraw-Hill, 2005.

58.

Cicchetti

La progettazione organizzativa. Franco Angeli, Milan, Italy, 2004

59.

Daley

Vasu

Supervisory perceptions of the impact of public sector personnel practices on the achievement of multiple goals. Putting the strategic into human resource management. American Reviews of Public Administration. 2005; 35: 157–167.

60.

Cicchetti A. (ed.) I Dipartimenti Ospedalieri nel Servizio Sanitario Nazionale (Hospital Clinical Directorates in the National Health Service). Milan, Italy: Franco Angeli, 2012.

61.

Kimberly

Evanisko

MJ.

Organizational innovation: the influence of individual, organizational and contextual factors on hospital adoption of technological and administrative innovations. Acad Manage J 1981; 24: 689–713.

62.

Katz

The effects of group longevity on project communication and performance. Admin Sci Quarter 1982; 27: 81–104.

63.

Damiani

Ricciardi

Manuale di programmazione e organizzazione sanitaria. Idelson- Gnocchi, 2010.