Caterina Galdiero Dottore di ricerca Università degli Studi di Napoli Federico II Dipartimento di Economia Aziendale

Transcription

1 Riccardo Mercurio Professore Ordinario di Organizzazione Aziendale Università degli Studi di Napoli Federico II Dipartimento di Economia Aziendale Marcello Martinez Professore Ordinario di Organizzazione aziendale Dipartimento di Strategie aziendali Seconda Università degli Studi di Napoli Caterina Galdiero Dottore di ricerca Università degli Studi di Napoli Federico II Dipartimento di Economia Aziendale Marina Cerbo Direttore del dipartimento innovazione e sviluppo Agenas Agenzia Nazionale per i Servizi Sanitari Regionali cerbo@agenas.it Maria Rosaria Perrini Sezione ISS - Innovazione, Sperimentazione e Sviluppo Agenas - Agenzia Nazionale per i Servizi Sanitari Regionali Agenas perrini@agenas.it

2 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, , 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

3 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,

4 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 healthcare 1. 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

5 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 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) Specialization Spa Rehabilitation Hospital, Motta di Livenza (TV) Ltd IRST Meldola (FC) Montecatone spa Imola (BO), New Civil Hospital of

6 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.

7 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; - 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

8 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 Level of organizational maturity Process of finalizing agreements with the regional health system 3 estabilished Process of evaluation and monitoring of health services accounted ASL 3 estabilished

9 Process control and evaluation of the objectives of the contract Assessment process and control of risk management Process measurement and control of patient 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 3 estabilished Process evaluation and incentive system for managers Process of staff planning, recruitment, staff training, incentives Process of evaluation and monitoring of individual and incentive Process of evaluation and control of occupational safety Low 5 optimizing 5 optimizing 5 optimizing 3 estabilished Process of internal communication Low 2 managed Processo of total quality Medium 4 predictable Process and system of delegation and proxies Medium 3 estabilished Strategic Planning Process Medium 3 estabilished Process Budgeting 5 optimizing Process of organizational change 4 predictable Process of providing goods and services Medium 4 predictable Process of assessing and monitoring the investment Process of managing ICT investments and new health technologies Medium 4 predictable 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

10 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.

11 Bibliografia Amatucci F., Lecci F., (2006), Le operazioni di partner-ship finanziaria pubblico- privato in sanità: una analisi critica, in E. Anessi Pessina, Cantù E.(cura di), Rapporto OASI 2006, Egea, Milano, pp Amatucci F., Lecci F., Marsilio M., (2007), Le sperimentazioni gestionali per i servizi core: ricognizione delle esperienze e analisi di due casi, in E. Anessi Pessina, Cantù E.(cura di), Rapporto OASI 2007, Egea, Milano, pp Anselmi L. (1997), Opportunità per la costituzione di società miste in sanità, Organizzazione sanitaria, 6, pp Anessi Pessina E., Cantù E. (2007), L aziendalizzazione della sanità in Italia. Rapporto OASI 2007, Egea. Anselmi, L. (2003), Percorsi aziendali per le Pubbliche Amministrazioni. Giappichelli, Torino. ASSR (2004), Relazione Progetto sperimentazioni e innovazioni gestionali, Barnett P., Perkins R., Powell M. (2001), On a Hiding to Nothing? Assessing the Corporate Governance of Hospital and Health Services in New Zealand, , International Journal of Health Planning and Management, 16: Borgonovi E. (2002), Principi e sistemi aziendali per le amministrazioni pubbliche. Egea, Milano. Borgonovi E. (2000), governare l amministrazione pubblica con il sistema a rete. Azienda Pubblica n.4. Bovaird T., Löffler E. (2001), Emerging Trends in Public Management and Governance, Teaching and Research Review, (Issue 5), Winter, Bristol Bussiness School, University of the West of England, UK. Bovaird T., Löffler E. (2002), Moving from Excellence Models of Local Service Delivery to Benchmarking Good Local Governance, International Review of Administrative Sciences, 68: Burns J., Crawford, J. K. (2002). Organizational project management maturity at The New York Times: Using the project management maturity model. Proceedings of the 33rd Annual Project Management Institute 2002 Seminars and Symposium, San Antonio, TX, [CD- ROM]. Newtown Square, PA: Project Management Institute. Cappellaro G., Marsilio M., (2007), Le collaborazioni Pubblico Privato per la gestione dei servizi sanitari: riflessioni alla luce della ricognizione delle esperienze internazionali e nazionali, Mecosan, 63, pp.9-36 Comacchio A., (1994), Il management dell'innovazione, UTET Libreria, Torino. Cooke-Davies, T. J. (2004). Project management maturity models. In J. K. Pinto & P. W. G. Morris (Eds.), The Wiley guide to managing projects (Chapter 49). New York: Wiley. Costa, G. Nacamulli, R.C.D. (1996). Manuale di Organizzazione aziendale. Vol. 1, Utet, Torino. Cepiku D. (2005), Governance: riferimento concettuale o ambiguità terminologica nei processi di innovazione della P.A.?, Azienda pubblica, 1: Cicchetti A., Cipolloni E., De Luca A., Mascia D., Papini P., Ruggirei M. (2006), L analisi dei network organizzativi nei sistemi sanitari: Il caso della rete di emergenza della Regione Lazio, Politiche Sanitarie, 7. CMMI Product Team. (2002). Capability maturity model integration (CMMI) Version 1.1. Pittsburgh, PA: Carnegie Mellon Software Engineering Institute. Cook J., Deakin S. (1999), Stakeholding and corporate governance: theory and evidence on economic performance, ESRC Centre for Business Research

12 Cuccurullo C., (2005), I meccanismi di governance nelle collaborazioni formali tra pubblico e privato in sanità, Mecosan, 54, pp Cuccurullo C., Tommasetti A. (2002), Le collaborazioni tra pubblico e privato in sanità: configurazioni organizzative e finalità strategiche, Mecosan, 44: D Atri A., (2004), Innovazione organizzativa e tecnologie innovative, ETAS, Milano Deakin S., Hughes A. (1997), Comparative corporate governance: an interdisciplianry agenda, in S. Deakin e A. Hughes, Enterprise and Community, Oxford, Basil Blackwell, 1997 Decastri M., - Paparelli A.,(2008), Organizzare l'innovazione. Una guida per la gestione dei processi innovativi aziendali, Hoepli, Milano. Del Vecchio M. (2003), Le aziende sanitarie tra specializzazione organizzativa, deintegrazione istituzionale e relazione di rete pubblica, Mecosan, 46, pp de Vita P., Mercurio R., Testa F. (2007), Organizzazione aziendale: assetto e meccanismi di relazione, Giappichelli, Torino. de Vita P., Martinez M. (2001), Flessibilità e performance dei sistemi di public utilità. Costa G. (a cura di). Flessibilità e performance. L organizzazione aziendale tra old e new economy, ISEDI, Torino. Donaldson T., Preston L.E. (1995), The stakeholder theory of corporation: concepts, evidence and implications, «Academy of Management Review», vol. 20, n. 1, pp Faillace R. (2005), le sperimentazioni gestionali in sanità: il caso Volterra in toscana, Mecosan, 54, pp Fattore G. (2004), L aziendalizzazione della sanità in Italia: la prospettiva dei consulenti, Anessi Pessina E., Cantù E. (a cura di), Rapporto OASI 2004 L aziedalizzazione della sanità in Italia. Egea Freeman R.E., Reed D.L. (1983), Stockholders and Stakeholders: A New Perspective on Corporate Governance, «California Management Review»,vol. 25, pp Freeman R.E. (1994), Strategic management. A stakeholder approach, Boston [Mass.], London. Pitman. Freeman R.E., Evan W.M. (1990), Corporate governance: a stakeholder interpretation, «Journal of Behavioral Economics», vol. 19, n. 4, pp Galdiero C. (2009), Il cambiamento istituzionale e la governance dei servizi pubblici: la ricomposizione del campo sanitario italiano alla ricerca di una nuova compliance, Martinez M. (a cura di). Cambiamento organizzativo e compliance. Assunti teorici e ricerche empiriche. Editoriale Scientifica, Napoli. Galdiero C., Cicellin M. (2009), Soft Coordination Mechanisms to Integrate Institutional Logics in Public-Private Partnerships, Mecosan, 71: Keasey K., Wright M. (1997), Introduction: the corporate governance problem - competing diagnoses and solutions, a Corporate Governance: economic, managment, and financial issue, Keasey et alii (a cura di), Oxford, O.U.P. Kickert W.J.M. (1997), Public Governance in the Netherlands: An Alternative to Anglo- American Managerialism, Public Administration, 75: Kickert W.J.M. (2003), Beneath Consensual Corporatism: Traditions of Governance in the Netherlands, Public Administration, 81(1): Kickert W.J.M. (2004), Distinctiveness of the Study of Public Management in France, Germany and Italy, IRSPM VII Confrence, Budapest. Kooiman J., Van Vliet M., Jentoft S. (1993), Governance and Public Management, in Eliassen K.A., Kooiman J., (ed.), Managing Public Organizations: Lessons from Contemporary European Experience, Sage Publications, London.

13 Lega F.(2006), Vincere la resilienza al cambiamento: come le aziende sanitarie stanno affrontando le sfide dell innovazione strategica e del cambiamento organizzativo, Anessi Pessina E., Cantù E. (a cura di), Rapporto OASI 2006 L aziendalizzazione della sanità in Italia. Egea, Milano. Lynn L., Hill C. (2003), What Do We Know About Governance? An Analysis of Empirical Research, EGPA Annual Meeting, Oeiras. Longo F. (2006), Governance delle reti di pubblico interesse: quali strumenti manageriali per rispondere ai problemi attuativi?, Azienda Pubblica, 1: Mayer F. (1997), Corporate governance, competition and performance, in Enterprise and Community: New Directions in Corporate Governance, a cura di S. Deakin e A. Hughes, Oxford, Blackwell, 1997 Mayntz R. (2003), From Government to Governance: Political Steering in Modern Societies, Summer Academy on IPP, Wuerzburg. Martinez M. (2009), Cambiamento organizzativo e compliance. Assunti teorici e ricerche empiriche, Editoriale Scientifica, Napoli. Mapelli V. (a cura di) (2007), I sistemi di governance dei Servizi sanitari regionali, Quaderni, 57: 317, Formez, Roma. Marsilio M., Mirano F. (2003), Sperimentazioni gestionali in sanità: il caso AMOS spa, l azienda multiservizi ospedalieri e sanitari del quadrante tre di Cuneo, Mecosan, 50, pp Mascia D. (2009), L organizzazione delle reti in sanità, FrancoAngeli, Milano. Meneguzzo M. (1995), Dal New Public Management alla Public Governance: il pendolo della ricerca sulla amministrazione pubblica, Azienda Pubblica, 3: Meneguzzo M. (1997), Ripensare la modernizzazione amministrativa e il new public management. L esperienza italiana: innovazione dal basso e sviluppo della governance locale, Azienda Pubblica, 6: Meneguzzo M. (2000), I terreni dell innovazione organizzativa: le reti sanitarie multiospedaliere e multi servizi, in Bergamaschi M., (a cura di). L organizzazione nelle aziende sanitarie, McGraw Hill, Milano, OECD (1999), Principles on Corporate Governance, SG/CG (99)5, Pierre J. (2000), Debating Governance: Authority, Steering and Democracy, University Press, Oxford. Rebora G., Arnaboldi M., Azzone G., (2007), Il change management nelle imprese e nelle pubbliche amministrazioni. Atti del Workshop (Castellanza, 5-6 giugno 2006), Aracne, Roma Rhodes R.A.W. (1992), Beyond Whitehall: Researching Local Governance, Political Studies, 44: Rhodes R.A.W. (1996), The New Governance: Governing Without Government, Political Studies, 44: Rhodes R.A.W. (1997), Understanding Governance, Policy Networks, Governance, Reflexivity and Accountability, Open University Press, Buckingham. Rhodes R.A.W. (1998), Understanding Governance: Comparing Public Sector Reform in Britain and Denmark, Scandinavian Political Studies, 22(4): Rhodes R.A.W. (2000), The Governance Narrative. Key Findings and Lessons from the ESRC s Whitehall Programme, Public Administration, 78: Rhodes R.A.W. (2008), Policy networks, in Galligan B., Winsome R., (ed.), The Oxford Companion to Australian Politics, Oxford University Press. Rossi G. (2003), Il conflitto epidemico, Milano, Adelphi

14 Rosenstock, C., Johnston, R. S., & Anderson, L. M. (2000). Maturity model implementation and use: A case study. Proceedings of the 31st Annual Project Management Institute 2000 Seminars and Symposium, Paris, France, [CD-ROM]. Newtown Square, PA: Project Management Institute. Slinger G., Deakin S. (1999), Regulating stakeholder relations, ESCR Centre for Business Research, Cambridge