Decoupling strategic planning in public healthcare organizations: do strategic documents explain strategy?

In this paper we aim to provide further knowledge and evidences on the many uses and scopes that strategic planning play for public healthcare organizations, and how their pattern of strategy-making is strongly influenced by neo-institutionalism. We provide an analysis through which we decouple the large portfolio of strategic planning documents that Italian public healthcare organizations are expected to deliver or autonomously decide to develop. In the last decade, interest among scholars has been increasing with respect to the strategic planning in the public healthcare sectors. Common idea is that better tools are required to achieve better performance. This view has been strongly influenced and supported by the rationalism of New Public Management (NPM) reforms. NPM has stressed that public sector organizations must adopt strategic planning practices to improve their long-term management, to guide public institutions, and to advance their performance in an increasingly turbulent context. Public healthcare organizations (PHOs) of developed countries have not escaped these paths. On another side, many academicians and practitioners state that strategy does not exist in public sector. Public organizations are political and ethical in nature. Politicians take all the most important decisions. As a famous proverb states, truth is the middle. Strategic planning is much needed to confront and create a sustainable future, but certainly is not easy as textbook often preach. There is a widespread consensus with respect to the public nature that it produces clear effects on an organizational context. Doing strategy-making in public healthcare organizations is peculiar because to several aspects of the external and internal circumstances of public organizations: - variety of stakeholders who place demands and constraints on the managers and expect services to be responsive to their specific needs; - political constraints that result in multiple goals less clear than those of private entities, as politicians do not like to commit themselves when issues are sensitive, frequent policy changes and the imposition of short time horizons on public managers; - distinctive goals such as equity and accountability that do not exist in the private sector (Flynn, 1997); - greater bureaucracy, decreased managerial autonomy, lower level of organizational commitment, because of inflexibility in personnel procedures and weak links between performance and rewards. In this light, discourse and political factors are often behind the success or failure of strategizing in public contexts in which a plurality of diverse actors come together to define goals and implement the actions. As the strategy-as-practice approach suggests, strategy-making in public healthcare organizations often is the result of the interplay of organizational discourse and politics in a public arena. Therefore, strategic documents might not be used as originally intended, as they often respond more to institutional isomorphism than to strategy-making processes. After more than 15 years of managerialization of the Italian NHS, strongly influenced by NPM principles, we studied as public healthcare organizations are using strategic documents to support their true strategymaking processes and decisions, or whether these documents serve different scopes, such as those highlighted by literature: consensus-building, advertising, testing internal management competences, respond isomorphically to institutional requests. Therefore, we investigated the portfolio of strategic documents of public healthcare organizations to assess: - whether there is a logical consistency in them, in terms of timing, coordination of contents, prioritization; - or whether documents are the results of disjointed processes, have different scopes unrelated to strategic planning, overlap and contradict in contents.