1
Classe di Scienze Sociali
Settore di Scienze Economiche e Manageriali
O
RGANIZATIONAL
C
OMMITMENT
S
TRATEGIES IN THE
H
EALTH
C
ARE
S
ECTOR AND THE
R
OLE OF THE
B
UDGET
Candidate
Margherita Bafaro
Supervisor Tutor
Milena Vainieri Alessio Moneta
2 INDEX
1. INTRODUCTION ... 3
2. ORGANIZATIONAL COMMITMENT: WHAT IT IS, WHY IS IMPORTANT AND HOW CAN BE FOSTERED……... 4
3. PARTICIPATIVE GOAL SETTING AND FEEDBACK TO ENHANCE ORGANIZATIONAL COMMITMENT IN HEALTHCARE SETTINGS……….……10
3.1. Behavioral accounting: the behavioral component in management control systems………10
3.2. Healthcare professionals and the budget system……….14
3.3. Participation to goal setting and organizational commitment in healthcare settings………..….17
3.4. Feedback and organizational commitment in healthcare settings……….….20
3.5. Research question………..24
4. THE EMPIRICAL EVIDENCE FROM THE TUSCAN HEALTH CARE SYSTEM...27
4.1. The Italian National Health Service and the role played by the budgetary system………..…27
4.2. The model……….………29 4.3. Data………31 4.4. Results……….35 4.5. Discussion……….……….37 5. CONCLUSION...40 6. REFERENCES...42
3 1. INTRODUCTION
The health care system has been involved in many changes in recent years. Since the coming of New Public Management (Mercurio and Martinez, 2010), health organizations have recognized the need for a more effective and efficient use of resources to enhance the organizational performance and the success of the entire national health system (Macinati and Pessina, 2014). To achieve this, the commitment and the engagement of clinical employees is essential in that they are responsible for the quality of care delivered to patients (Mosley, 2014; Bini, 2015). Alignment of organizational and physicians' goals is therefore crucial for enhancing the effectiveness of the health care system. In order to guide employees' behaviour diverse engagement strategies have been studied over the years (Malmi and Brown, 2008).
In this regard, also the budget system can be a great tool in order to foster workers’ organizational commitment, but its effectiveness highly depends on its perceived utility and actual use (Otley, 1978). From a procedural point of view, participation and feedback may be the key success factors in order to transform the budget system from a static cybernetic exercise to an effective engagement tool perceived as useful by workers.
This research aims to understand the complex relationship between overall engagement strategies, budget specific engagement strategies, budget perceived utility and workers’ organizational commitment in order to give some insight on how the budget system should evolve in order to have the most impact on healthcare organizations.
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2. ORGANIZATIONAL COMMITMENT: WHAT IT IS, WHY IS IMPORTANT AND HOW CAN BE FOSTERED
Organizational commitment can be defined as the “willingness of employees to make greater effort on behalf of their organizations, a strong desire to remain in their organizations and accept their major goals and values” (Porters, Steers, Mowday & Boulin, 1974).
According to the research carried out by Allen and Meyer (1990), three distinct components may characterize organizational commitment: the affective, continuance and normative components.
The affective component, the most important according to Rhoades, Eisenberg and Armeli (2001), refers to the employees’ identification and involvement with their organizations because they want to (Allen & Meyer, 1991). The continuance component refers instead to the employees’ evaluations of the costs of leaving or discontinuing a particular activity in their organizations: indeed, these employees will stay with their organizations because they perceive small and poor alternatives or high costs associated with leaving (Allen & Meyer, 1990). Finally, the normative component entails a sense of obligation to the organizations: according to Allen and Meyer (1990), they feel responsible and loyal to their organizations because it is the correct and moral thing to do. From the above-mentioned definitions, we can therefore see that there is a strong correlation between organizational commitment and individual motivation: overall, organizational commitment is all about aligning effort and motivation to organizational goals. Also Beckeri, Randal, and Riegel (1995) defined organizational commitment as composed by three main pillars: a strong desire to remain a member of a particular organization, a willingness to exert high levels of efforts on behalf of the organization and a define belief in and acceptability of the values and goals of the organization. To Northcraft and Neale (1996), commitment is an attitude reflecting an employee's loyalty to the organization, and an ongoing process through which organization members express their concern for the organization and its continued success and well-being. Therefore, organizations are extremely interested to improve organizational commitment since commitment binds an individual to an organization and thereby reduces the likelihood of turnover (Tella et al., 2007).
Many researchers have analyzed the relationship between organizational commitment and work engagement and have have always been found a tight connection between the two
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constructs (Chalofsky &Krishna, 2009). Most research incorporates the concept of organizational commitment as an aspect of work engagement (Field and Buitendach, 2011). Indeed, empirical evidence finds a strong and positive link between organizational commitment and work engagement (Rothmann and Jordaan,2006), where the concept of work engagement refers to an “active, positive and fulfilling work-related state of mind that is characterized by vigor, dedication and absorption” (Schaufeli and Bakker, 2004).
In our study we will use the definition of organizational commitment already used in the UK’s civil service people survey (UK Cabinet Office, 2013;) that is one of the largest attitudes surveys carried out in the United Kingdom every year. In brief, the UK survey articulates the concept of organizational commitment through five separate components (Field and Buitendach, 2011): pride, advocacy, attachment, inspiration and motivation.
Pride. The pride component measures how much employees are proud of telling others to be part of a given organization. The relational underlying this measure is that employees who are engaged with an organization are proud to be associated with it rather and shoe higher levels of organizational commitment.
Advocacy. Employees with high levels of advocacy tend to recommend their organizations as a great place where to work, therefore spreading a positive word-of-mouth and supporting the overall image of their organization. An engaged employee will be an advocate of his organization and its overall way of functioning.
Attachment. Employees who feel a strong personal attachment to their organizations are likely to be very engaged within the workplace given that an engaged employee usually has a strong and emotional sense of belonging to their organization.
Inspiration. The inspirational component plays a crucial role in the organizational commitment concept in that engaged employees will contribute their best but it is important that their organizations strive for inspiring this positive attitude.
Motivation. Least but not last, an employee is committed to ensuring its organization is successful in reaching the set goals: motivation is therefore a fundamental component to help individuals achieve organizational objectives.
Organizational commitment is therefore found to directly affect employees' behavior (MacLeod and Clarke, 2011). While performance remains the upmost concern in today's
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organization, there are other sought-after behaviors that organizations strive to enhance and organizational commitment may foster.
Performance. Work performance is described as the quality and quantity of human output that is necessary to meet work goals and the standards that are required to do a specific job (Ivancevich & Matteson, 1996). Bakker (2009) shows in his research four main relationships between organizational commitment and better employee performance: engaged employees (a) often experience positive emotions, including happiness, joy and enthusiasm; (b) experience better psychological and physical health; (c) create their own job and personal resources; (4) transfer their engagement to others). These four points explain the main reasons why an engaged workforce is more productive than a non-engaged workforce is, and other many studies confirmed the positive relationship between organizational commitment and performance (Rich et al. 2010; Guest, 2014). A more focused study on motivation carried out by Wood and Bandura (1989) set up an experiment (a management simulation) where both goals and self-efficacy enhanced the performance of the subjects in the simulation. The mechanisms through which motivation - enhanced for instance through goals, expectancies and self-efficacy - affects performance are relatively well understood. For example, high-goals and high self-efficacy lead individuals to persist longer at tasks and exert more effort than their peers low in goal difficulty and self-efficacy (Bandura, 1986; Locke et al., 1984; LaPorte and Nath, 1976). It is therefore natural that motivated employees will outperform unmotivated ones: the former put more effort, persistence and attention to reach the desired performance outcome in comparison the latter.
Other sought-after employees' behaviors . In addiction to performance, there are many specific behaviors sought-after by organizations that are positively enhanced by organizational commitment. Some examples of these behaviours are knowledge sharing, job attendance and organizational citizenship behaviour. Knowledge sharing is one of the major challenges in today's organisations (Wulff and Ginman, 2004). Dyer and Nobeoka (2000) define knowledge sharing as the activities of how to help communities of people work together, facilitating the exchange of their knowledge, enhancing organizational learning capacity, and increasing their ability to achieve individual and organizational goals. In 2007, Hsiu-Fen Lin empirically tested the relationship between motivation and employees' propension to knowledge sharing: he found that both intrinsic and extrinsic motivation enhanced employees' willingness to
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information sharing. Another example of how organizational commitment enhances sought-after employees' actions is its impact on job attendance. As argued by Bandura (1997), motivation increases employees' self-efficacy and this, in turn, positively impact on their job attendance. Finally, it may important to pay attention to employees' organizational commitment given its impact on organization citizenship behavior. Organization citizenship behavior is defined as an "individual behavior that is discretionary, not directly or explicitly recognized by the formal reward system, and that in the aggregate promotes the effective functioning of organizations" (Organ, 1988, p.4). One research (Chahal and Mehta, 2010) found that organizational commitment plays an important role in strengthening organizational citizenship behavior (OCB), especially when employees are at the bottom of the organizational pyramid. Indeed, by encouraging employees to actively participate in decision making, management can help in coordinating efforts among team members. In turn, this positively contributes to group effectiveness and efficiency.
In relation to the key drivers of organizational commitment, researchers found many antecedents of the construct (Rich et. Al, 2010; Bakker, 2009; Guest, 2014): perceived organizational support, high levels of congruence (i.e. organizational fit), opportunities for learning, perceived self-efficacy, job-variety, task significance, workplace culture, inclusion and fair treatment and many others. In our analysis we will mainly focus on two fundamental drivers of organizational commitment, which are also crucial to the five “raw” components of the concept: feedback and participation to decision making.
Feedback. Feedback is often described as an information provided to an individual for the purpose of an increase in performance (Earley, Northcraft, Lee, & Lituchy, 1990; Kluger & DeNisi, 1996). Feedback is characterized by many aspects (Balcazar, Hopkins, & Suarez, 1986, namely the type of feedback (outcome vs process feedback), the feedback nature (positive vs negative), the feedback recipients (individuals vs teams), the feedback source (subordinates vs supervisors vs peers) and the feedback intervention (evaluative vs developmental reasons) (Geister et al., 2006).
There are many ways through which feedback is found to affect organizational commitment. The first is through the enhancement of the perceived self-efficacy in case of positive feedback
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(Schunk, 1995; Schunk, 1989). This finding is extremely coherent with self-efficacy theory and the role of verbal persuasion (Bandura, 1977).
Second, feedback improves organizational commitment and, together, motivation through the enhancement of the sense of competence (Deci, 1971; Arnold, 1985). This evidence is also coherent with self-determination theory. Indeed, on the one hand positive feedback is associated with an increase in work motivation because the sense of competence is empowered, however too much feedback makes the person dependent on it and leads to a decrease in intrinsic motivation. Negative feedback, on the other hand, affects the sense of competence of an individual providing him with a feeling of failure and inadequacy, thus decreasing intrinsic motivation when too much negative feedback is provided. However, a small amount of negative feedback could challenge the person and push him to perform more and better, improving consequently his intrinsic motivation.
Finally, feedback increases employees’ organizational commitment through its informational content because it may re-direction individuals' efforts towards specific goals therefore enhancing individuals’ motivation.
Participation. Participation to decision making within organizations is studied both in job design and in organizational culture literatures. In both cases, the more organizations involve employees and empower them in the decision making process, letting them actively participate in decisions, the more employees will pay back by increase their organizational commitment to the firm and, finally, their performance.
Job characteristics such as the amount of variety, responsibility, and interpersonal relations at the workplace are found to be strongly related to employees' organizational commitment and behavior (Hackman & Lawler, 1971). Hackman, Oldham, Janson, and Purdy (1974) hypothesized that experienced meaningfulness, experienced responsibility, and knowledge of results are highly predictive of motivation and commitment on the job. According to Hackman et al., these states are present when the job content is high on the following five core job characteristics: skill variety (the opportunity to use a number of different skills on the job); task identity (the opportunity to complete a meaningful, whole piece of work); task significance (the opportunity to perform a job that affects the well-being of other people); autonomy (the opportunity to make decisions relating to the work process); feedback. Thus, job design programs have focused on six job dimensions in order to improve employees' motivation and performance:
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the variety of tasks performed and skills employed, responsibility for and control over the work process, completion of meaningful units of work, feedback, interpersonal interaction, and learning (Rousseau, 1977; Walton, 1972; Dowling, 1973).
Organizational culture is the specific collection of values and norms that are shared by the people and groups in an organization and that control the way the employees interact with each other and with stake holders outside the organization. More in particular, in Schein provided a well- accepted definition of corporate culture as "the pattern of basic assumptions that a given group has invented, discovered, or developed in learning to cope with its problems of external adaptation and internal integration and that have worked well enough to be considered valid, and, therefore, to be taught to new members as to correct way to perceive, think, and feel in relation to those problems".
Organizational culture is found to strongly affect employees' organizational commitment in many circumstances. Hartmann and Hartmann (2001) argue instead that organizational culture plays a critical role in motivating innovative behaviour, as it can create commitment among members of an organization in terms of believing in innovation as an organizational value and accepting innovation‐related norms prevalent within the organization. Moreover, Cheeran, Saji and Joseph (2015) found that a strong organizational culture, fostering the perceived integrity and the feeling of belongingness among employee's, improves employees' organizational commitment. As a result, it leads to improve in employee performance. Employee must be given a chance of involvement in the organization decision making. If they participate in the functioning of the organization they will feel themselves as a part of organization and therefore will be more motivated to achieve both individual and organizational level results.
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3. PARTICIPATIVE GOAL SETTING AND FEEDBACK TO ENHANCE ORGANIZATIONAL COMMITMENT IN HEALTHCARE SETTINGS
In this chapter participation to goal setting and feedback are contextualized in the broader framework of management control and performance management systems. After a brief introduction on behavioural accounting management and a focus on the complex relationship between healthcare professionals and the budget system, the research will discuss the role participation to goal setting and feedback have on workers’ organizational commitment (both in relation to general engagement strategies and budget specific engagement strategies).
3.1 BEHAVIORAL ACCOUNTING: THE BEHAVIORAL COMPONENT IN MANAGEMENT CONTROL SYSTEMS
Management control systems (e.g. budget system) provide information that is intended to be useful to managers in performing their jobs and to assist organizations in developing and maintaining viable patterns of behaviour (Otley 1999). Indeed, the main objective of management control systems is to align individual behaviours with the overall organization goals (Marasca et al., 2013).
The management literature has widely supported the behavioural component and the human dimension in the control systems (Merchant and Riccaboni, 2003). Indeed, an example is given by Flamholtz et al. (1985), who define motivation as a process through which behaviour, both at the organizational and individual level, can be influenced. Since management control systems direct individuals' behaviour through goal-setting and the information provided, their implementation necessarily entails the understanding of the antecedents of human behaviour (Macinati, 2012).
These behavioural aspects of control systems have been studied since 1950 under the name of behavioural management accounting. Starting from the United States of America, the research on this topic intensified till the '70, then it slowed down and increased again after the 80's. In particular, Argyris (1952) is acknowledged as the pioneer of behavioural accounting research. He stressed how processes and techniques of management control influence individual motivation, social interaction and the factual use of the information provided by the system itself.
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The studies carried out in relation to the impact of management control systems on individual behaviour often employ laboratory experiments (Evans, 2005) as in the field of psychology research. However, also surveys (Clinton and Hunton, 2001) are sometimes used to understand the relationship between control systems and motivation.
The research on behavioural management accounting found that managerial control systems affect individuals' behaviour through mainly two effects (Macinati, 2012; Binberg, 2011): a motivational effect and an informational effect. These effects directly relate to the intimate nature of control systems, at the same time operational mechanisms to direct employees' actions and informational systems in support of decision making.
As far as the informative effect is concerned, individuals memorize, research and use the information provided by the control systems following a heuristic approach. The control systems themselves influence the choice of the used heuristic processes and impact on how individuals develop mental representations and perceptions concerning the organization as a whole (Macinati, 2012). In other words, the more information employees will get, the more they will perceive the utility of the control systems and consequently adjust their behaviours.
As far as the motivational effect is concerned, management control system techniques as budgeting should motivate individuals and teams towards the achievement of organizational goals. The motivational power of the control tools is strictly related to the individual psychological processes linked to the mental representation of aims and rewards through the processes of goal-setting, aspiration levels, perceived equity, etc. (Macinati, 2012).
In this regard, the research on behavioural management has focused on the following streams of research (Macinati, 2012): characteristics of budget goals; participation to management control process; role ambiguity; accountability; perceived procedural and organizational equity. The design of management control systems affects in many ways these variables which, in turn, affect individual behaviour and performance.
The study of the goal setting impact on individual behaviour is one of the first variables analysed in behavioural accounting research (Macinati, 2012). Stedry (1960) found that employees'
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performance is linked to goals' level of difficulty and to their assignment and communication process. In particular, if goals are communicated before the employee defines his aspirational levels, difficult objectives lead to higher levels of performance. Conversely, if the communication takes place after the employee set his level of aspirations, difficult goals have not any impact on performance since individuals usually keep their own set levels of aspirations fixed over time. Also Locke and Latham (2002) and Kenis (1979) found that the characteristics of assigned goal influence employees' levels of performance. On the one hand, they argue that both specificity and the degree of difficulty positively influence individuals' motivation to reach the assigned goals. On the other hand, they found that feedback over results is not relevant in motivating individuals. On the contrary, Hirst and Lowy (1990) found that the relationship between goal difficulty and performance is moderated by feedback over goal achievement. Tiller (1983) took into account another factor to study the effect of different budgeting practices on individual behaviour: goal participation. He found that when employees have the opportunity to participate within the budgeting process, when they can themselves contribute to their goal-setting, performance increases as goal difficulty goes up. The cognitive dissonance the employee would experience if he could not reach the objective himself once negotiated leads him to improve his commitment and effort towards goal achievement.
In this regard, also budget participation is a recurrent variable in behavioural accounting research (Macinati, 2012). While at a first moment the literature suggested that participation in the budgeting process fosters employees' goal acceptance and motivate them to behave coherently, more recent studies (Renn, 1998) focused on the importance of participation to reduce employees' reluctance to pursue externally set objectives and to enhance their perceived control over events. In turn, these effects translate to a better acceptance of budget decisions and a better performance (Shields and Shields, 1998). For instance, Shield et al. (2000) demonstrated that participation to the budget process influences performance through three main channels. First, participation improves the perceived control over events, that in turn decreases individual stress. Second, thanks to their participation to the whole process, employees gain the opportunity to set themselves objectives and therefore to set them within their own desirable ranges. Finally, through participation it is enhanced the role of incentives in directing employees' efforts.
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Brownell and McInnes (1986) found that participation to the budget process enhances two motivation related variables: the expectancy of success (that is the likelihood set by the individual that the efforts will lead to goal achievement) and the instrumentality (that is the likelihood set by the subject that goal achievement will lead to the expected rewards).
Finally, at the team level, Chalos and Poon (2000) found that participation to the budget process improves the performance of involved individuals, however if redundant information is provided, the share of the information within the group reduces the accuracy of budget appraisal and the speed of decision making.
Another stream of research analyzed the influence of management control systems on the perceived role ambiguity (Macinati, 2012). It is indeed very important to strive for reducing role ambiguity because the empirical evidence suggests found a negative relationship between role ambiguity and performance (Tubre and Collins, 2000). Management control systems play a pivotal role in decreasing employees' role ambiguity. Collins (1982) found that control systems entail relevant information which can enhance employees' role awareness in organizations. Indeed, the budget system sets explicit goals and supports coherent behaviours for goal achievement, in turn reducing individuals' role ambiguity. Moreover, also the reporting system helps individuals to better understand the overall organizational functioning and their specific role within the firm (King and King, 1990).
Accountability is also an interesting factor taken into account in the behavioural accounting research (Macinati, 2012). Hopwood (1973) argues that the use of information stemming from management control systems for evaluative purposes may produce dysfunctional behaviours as gaming and competition within teams. In particular, he argues that negative behaviour consequent to evaluation is not linked to the technical characteristics of management control systems but, rather, to the factual use that superiors make of the information itself. How the information is handled rather than what it entails is found to be relevant.
A fifth stream of research focuses on perceived justice (Macinati, 2012). Hufnagel and Binberg (1994) found that individuals are particularly sensible to procedural injustice linked to budget processes, even if their goals are in line with the organizational ones. Libby (1999) demonstrated that performance increases when individuals are given explanations about the
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goal-setting process in that it increases their perceptions of organizational justice. Moreover, he found that the likelihood of goal achievement increases if employees perceive the overall budget process as fair; conversely, performance decreases if both the budget itself and the budgetary process are perceived as unfair. These findings are really interesting, because they imply that the budget is not perceived as unfair until the overall budgeting process is deemed to be equal and fair. Again, how the process is handled is found to impact on employees' motivation and attitudes more than the results of the process itself.
To sum up, management control systems highly influence individuals' behaviours and decisions. Behavioural management accounting studied this influence through the impact control systems have on both content (e.g. characteristics of goals) and procedural variables (e.g. perceived equity of the budgeting process). A special attention is reserved to the role of goal-setting and feedback: both of them have a great relevance in influencing employees' behaviour. Given their importance, as already stressed, this research will specifically focus on their impact on budget effectiveness.m
3.2HEALTHCARE PROFESSIONALS AND THE BUDGET SYSTEM
Over the past years, in line with the advance of the New Public Management thought (Mercurio and Martinez, 2010), management control systems have gained importance in the healthcare sector as a means to enhance organizational effectiveness and efficiency (Macinati and Pessina, 2014). In this general framework, budgeting is a key element given the close relationship between clinical behaviour, efficient and effective decision-making and, finally, accounting information (Hood, 1995). Indeed, clinicians' decision making highly impacts on resource consumption and their effective use, therefore influencing the extent to which budget goals are met. The role healthcare professionals (e.g. physicians and nurses) holds in achieving budget goals is crucial but really complicated because of the intrinsic nature of clinicians' vocation.
On the one hand, healthcare professionals are in close contact with customers (patients) and take the most part of decisions in healthcare organizations (e.g. how to nurse patients). Indeed, as experts on the ground, physicians are the ones who can really understand the nature of
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problem (e.g. disease) and consequently provide a coherent solution (e.g. treatment). This is the reason why healthcare organizations are usually structured as an inverted pyramid (Mosley, 2014), where key decisions are taken at the bottom by physicians while top senior managers support and control their actions (see the figure below). In turn, these decisions taken at the bottom make the most part of the budget in health organizations (Tjosvold and MacPherson, 1996). Therefore, budget information should help budget holders' (physicians) to choose the best alternative in order maximize the results while minimizing the related costs. However, this would be true if and only if the budget holder would be a rational agent who is neutral to personal and professional considerations (Whitley, 1999).
Traditional and reverse hierarchy (adapted by Bini, 2015).
If any personal or professional consideration is taken into account, the relationship budget information - decision making process does not hold anymore: this is exactly the case for healthcare professionals. Indeed, physicians' sense of loyalty belongs more to their profession rather than to the organization they work for (Abernethy and Chua, 1996). Even among multiple trade-offs, patients' lives are the first and foremost interests of physicians (Baker and Denis, 2011). In turn, this may affect clinicians' acceptance of management control systems (MCS) and motivation to reach budget goals: "strong professional identification and emotional attachment to the profession can manifest themselves [physicians] through low commitment to reach organizational goals and result in a scarce attitude through managerial roles" (Macinati and Rizzo, 2014, p. 230). Physicians engagement in the budgeting process is therefore indispensable in order to reduce professionals' budget resistance and enhance both the organization clinical
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and financial performance (Spurgeon et al., 2011; Bini, 2015).
The paradox therefore lies on the fact that healthcare professionals are the ones who decide the most part of the budgetary content but, at the same time, they are not likely to adopt the budgeting framework to make effective and efficient choices for the organization they work for. Physicians' decisions dramatically impact on both resource efficiency and efficacy, but efficiency and efficacy considerations come always after the patient's interests. In this regard, the main challenge consists in engaging physicians into the budgeting process so that healthcare organizations' sustainability may be guaranteed in addition to the patient's interest in a cost-benefit perspective (Macinati, 2010; Macinati et al., 2012; Abernethy and Vagnoni, 2004). According to these principles, once completely autonomous in the name of a well-established "professional bureaucracy" (Mintzberg, 1979), physicians are now more and more forced to integrate healthcare plans with economic and cost efficiency considerations (Schwartz et al., 2000; Freidson, 2002) while in the past clinical and managerial/administrative responsibilities were drastically divided (Kitchener, 2002). However, if lack of identification with organizational goals occurs, this clinical-managerial integration may be perceived by physicians as distant from their values and as a direct assault upon the medical profession itself (Nylan and Pettersen, 2004; Kurunmaki, 1999; Maddock and Morgan, 1998), resulting in a high resistance to change. Again, the extent to which resistance to change will occur dramatically depends on the budget content, process design and its actual use (Macinati and Pessina, 2014). In particular, how a management control system is introduced and operates influences its future likelihood of success and acceptance.
To sum up, healthcare professionals are not rational agent in that their strong professional vocation usually prevents them to consider also sustainability issues. In order to incentivize physicians, nurses and all the other professions involved in the healthcare sector to adopt a managerial mind-set in addition to the clinical one, an engagement strategy has to be fostered. In particular, to enhance the likelihood the budget will be accepted and really perceived as useful in day-by-day activites, both content and process related issues must be taken into account. As suggested in the previous chapter, this dissertation will focus on the procedural traits of the budgeting system. In the next sections two procedural budgeting traits already analyzed in the previous chapter, that is goal participation and feedback, will be studied as
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engagement techniques of healthcare professionals in the budgeting system. In turn, we expect clinicians to be more commited and motivated by the budgeting process and its actual usage.
3.3 PARTICIPATION TO GOAL SETTING AND ORGANIZATIONAL COMMITMENT IN THE HEALTHCARE SETTING
In order to effectively influence individuals' behaviour, budget goals should be set taking into account the structure, the culture, the processes, the overall mission and all the other relevant traits which distinguish an organization from another. The process through which goals are set will be given particular attention: indeed, as it was discussed earlier, often how a decision is taken is perceived to be far more relevant than the decision itself by subordinates. Indeed, the perceived utility of the budget is crucial to its effective application in day-by-day activities.
Chong and Chong (2002) define budget participation as a "process whereby subordinates are given the opportunities to get involved in, and have influence on, the budget setting process. Previous definitions are given by Milani (1975) and Brownell (1979) who describe the construct as the amount of influence and involvement that an employee perceives he or she has on a jointly-set budget.
The main reasons why organizations should adopt a participative budgeting system are given by Shields and Shields (1998): in this regards, the authors discuss the relevance of vertical information sharing, coordinating interdependencies and motivation and attitudes. As far as the first reason is concerned, both the economics and psychological literature assume that participative budgeting is used to reduce environmental and task uncertainty: indeed, the subordinate has better information than the superior and therefore managers could better design incentive schemes and strategies by sharing information with employees. Other theoretical studies assume task interdependence and information asymmetry to be the root causes of the rise of participative budgeting in that it is used to "coordinate task interdependence between subunits under conditions of asymmetric information" (Shields and Shields, 1998, p. 60). Finally, psychological theory-based research assumes that participative budgeting exists to increase motivation and job satisfaction while decreasing job-related tensions.
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variables (Chong et al., 2006): role ambiguity, organizational commitment and job satisfaction. The first link is explained in the light of the cognitive role of participative budgeting: "the cognitive mechanism assumes that participative budgeting provides subordinates the opportunity to share their local and specialized knowledge with their peers and superiors, and permit open discussion of preferred means-end approaches" (p. 70). Hence, the cognitive role of participative budgeting is expected to lower employees' role ambiguity (H1). The second hypothesis (H2), also called motivation effect hypothesis, assumes that participative budgeting enhances subordinates' levels of organizational commitment: indeed, Nouri and Parker (1998) found that if employees are involved in the budgeting process they better understand budgeting goals and organizational objectives, while Shields and Shields (1998) stress the positive consequences on trust and acceptance over budget decisions. Finally, the third hypothesis (H3) is concerned with the relationship between participative budgeting and job satisfaction, therefore focusing on the so called value attainment role of participative budgeting. Furthermore, it is supposed that role ambiguity is negatively related to organizational commitment and job satisfaction, while organizational commitment is positively connected with job satisfaction; in turn, job satisfaction positively impacts on job performance. Given these relationships, Chong et al. suppose that an indirect relation exists between participative budgeting and job performance (H4): the former affects the latter through role ambiguity, organizational commitment and job satisfaction. The empirical evidence supports all four the hypotheses.
To analyse and support the motivational effect of budget participation (which we will focus on in this dissertation), Chong and Chong (2002) adopted the goal setting framework (e.g. Kren and Liao, 1988; Murray, 1990). The authors argue that budget participation may improve subordinates' budget goal commitment, that is "the determination to try for a budget goal and the persistence in pursuing it over time" (Locke et al. 1981, as cited by Chong and Chong, 2002, p. 68). Their paper justifies this assumption by stressing how the opportunity to influence the budget-setting process enhances subordinates’ feeling of control and involvement over the budget.
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Theoretical model of Chong and Chong (2002).
In turn, such feeling increases subordinates’ commitment to the budget goals. Therefore, similar to what supposed by Chong et al. (2006), they hypothesize that higher level of budget participation are associated with higher levels of goal commitment (H1), which in turn positively
affect the spread of job-relevant information (H2) and, finally, the overall job performance (H3).
Indeed, information exchange between subordinates and superiors leads to more accurate budgets and more realistic plans. The results of their analysis support all three the hypotheses, thus stressing the role of budget participation both in improving subordinates’ commitment and improving their job performance. Moreover, the same relationships have been tested by Macinati and Rizzo (2014), who confirmed the same results previously found in Chong and Chong (2002).
Budget participation was found to be critical also in in the healthcare setting. Indeed, the need for enhancing budget acceptance among healthcare professionals calls for an effective engagement strategy: participation to the budget process could be used as a lever to increase healthcare professionals’ commitment to the organization.
As it has been previously discussed, physicians assume an ambiguous position in the healthcare budgeting framework: they are the foremost decision makers but - at the same time - their clinical vocation usually make them disinterested towards organizational sustainability issues. As a matter of fact, the literature has focused on this particular category, almost unanimously acknowledging that participation in decision making strongly affect physicians' motivation, performance and overall commitment to organizations (Janus, 2010; Laubach and Fischbeck, 2007). Indeed, in their research Hagopian et al. (2009) find out that health workers' commitment generally dramatically increases when managers give them the chance to participate in meetings concerned with hospital issues.
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representatives (General Manager, Administrative officer and Controller) were interviewed. In most interviews, it comes out that the main reason why of the application of a participative goal setting is to motivate clinical managers to reach budget goals. In their goal-setting framework, Macinati and Rizzo found out that budgetary participation enhances clinical managers' motivation and commitment to organizational goals. In turn, this "suggests that the convergence between individual and organizational goals is a key factor in explaining the extent to which a management control system is used and, consistent with Otley’s reasoning can avoid information-disregarding phenomena" (p. 235). Moreover, the results of the evidence clearly show that clinical managers "indirectly translate a higher perceived level of involvement in the setting of the final budget into a higher level of use of budget information apparently because the involvement in the budget setting process stimulates greater ego-identification with budget goals that impact individuals’ intentions to act" (p.235).
To sum up, the literature focused on healthcare settings suggests that participation to goal setting enhances employees’ organizational commitment.
3.4 FEEDBACK AND ORGANIZATIONAL COMMITMENT IN THE HEALTHCARE SETTING
The value and importance of feedback to direct and motivate behaviour is well known. Feedback can be defined as "the degree to which the job provides clear information about performance levels" (Colquit, 2001) and it is part of the information flows system described by Ferreira and Otley. As such, feedback is an integral component of the performance
management process.
One useful distinction is the one between positive and negative feedback (also called feedback sign). Negative feedback indicates that one’s job performance is not meeting superiors' expectations and it is clearly of developmental value to an individual and of strategic value to organizations. Negative feedback is assumed to create awareness and motivate individuals to change behaviours. However, it is commonly accepted that negative feedback is perceived as less accurate and thus less accepted by recipients than positive feedback (Fedor et al., 1989; Ilgen et al., 1979). Positive feedback, on the other hand, is given after a positive performance in order to guide, motivate and reinforce effective behaviours and put a halt to ineffective behaviours. The effect of feedback sign on commitment and performance is however complex and unclear (Brett and Atwater, 2001; Reilly et al., 1996). De Nisi and Kluger (2000) discuss the motivational valence of feedback and its positive consequences on performance. However,
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even if in most cases feedback has a small positive effect on both motivation and performance, in 38% of cases it has the opposite effect. This happens irrespectively of the feedback sign. On the other hand, Kuvaas et al. found a stronger relationship than De Nisi and Kluger (2000) between feedback, motivation and performance. They argue that both goal setting and feedback are key performance appraisals activities in organizations and are found to positively affect performance through motivation. As Kuvaas et al., Roberts and Reed (1996) proposed that goal participation and feedback affect appraisal acceptance, which influences in turn appraisal satisfaction and finally employee motivation and productivity. Similar relationships are discussed in Pettijohn et al. (2001).
As stressed, feedback is one of the most powerful factor which affects learning and performance, but this impact can be either positive or negative (Hattie and Timperley, 2007). These ambiguities may be due to differences in individuals: Ilgen et al. (1979) argue that individuals interpret and respond to appraisal feedback in different ways, therefore influencing its effect of motivation and subsequent performance. For instance, employees with high intrinsic motivation view feedback as task oriented more than their peers with lower intrinsic motivation. In turn, task orientation should result in a learning improvement and performance enhancement (Kluger and DeNisi, 1996).
Now that the ambiguous effects of feedback on commitment and performance have been discussed, some contextual and configurational factors which could mediate the impact of feedback and alter its effectiveness will be analyzed.
Many researchers have focused on the mediating role of task complexity (Atkins, Wood, & Rutgers, 2002; Kanfer & Ackerman, 1989; Wood, 1986): according to them, when task complexity is high, feedback does not always improve employees' performance. This is due to the high uncertainty in which individuals work when they have to perform a complex task.
Kluger and De Nisi (1996) argue that if feedback is given in relation to a specific task and it is focused on learning contents, it will improve performance much more than general feedbacks which direct attention away of the task (e.g. feedback on the self rather than on the task). Therefore, according to De Nisi and Kluger (1996), feedback should be task specific in order to be effective. Other researchers suggest instead that if participants do not perceive the system to be fair, the feedback to be accurate, or sources to be credible then they are more likely not
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to use the feedback they receive (Levy and Williams, 2004; Facteau & Facteau, 1998; Ilgen et al., 1979; Waldman & Bowen, 1998).
Hattie and Timberley (2007) suggest that the power of feedback depends on the direction of the feedback relative to the performance on a task: according to the authors, feedback is more effective when it provides employees with information on correct responses, when it builds on changes from previous trails and when goals are specific and challenging but task complexity is low.
Van-Dijk and Kluger (2004) analyze the moderation effect of regulatory focus (Higgins, 1998) between feedback sign and motivation. They boil down to the conclusion that positive feedback is better than negative feedback when individuals are promotion-focused (e.g. if creativity is required to sort out the task), whereas it is true the reverse when people are prevention-focused (e.g. if adherence to rules is required on the job). However, Van Dijk and Kluger (2011) find ambiguous effects of negative feedback under the prevention focus. This may happen because - the authors explain- "negative feedback under prevention focus may simultaneously decrease the expectancy of future success but increase the value of future success" (p. 1101).
Vancouver and Tischner (2004) focus instead on the moderator role of task characteristics regarding the feedback sign and performance: according to their research, when cognitive resources are needed in order to perform the task, feedback sign is positively correlated with performance, whereas when cognitive resources are not required, positive feedback do not improve performance and negative feedback weakly increases performance.
Van Dijk and Kluger (2011) hypothesize that "for tasks that require vigilance and adherence to rules, negative feedback will increase motivation and performance more than positive feedback. For tasks that require eagerness and creativity, positive feedback will increase motivation and performance more than negative feedback" (p. 1088). Therefore, they stress that task type moderates feedback-sign effects on motivation and performance.
Finally, Steelman and Kutkosky (2003) focus on the effects of favorable contextual characteristics on the negative consequences of unfavourable feedback. Indeed, even if unfavourable feedback usually results in "negative attitudes, less acceptance of the feedback and unwillingness to change behaviour based on the feedback" (p. 1101), the authors find that
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"employees are most motivated to modify their job performance when unfavorable feedback is from a credible source, is of high quality or is delivered in a considerate and constructive manner" (p.1101).
From this brief literature review on the role of feedback and its relationship with motivation and performance it is clear that the impact feedback has on employees heavily depends on a) individual characteristics, b) task characteristics and c) feedback characteristics. Therefore, to successfully use this lever in any management control system, managers must pay a particular attention to the feedback recipient, the task assigned and other situational factors.
Also in the healthcare sector, feedback is seen to affect professionals' commitment to reach budget goals and to learn from previous errors. Indeed, it makes sense to hypothesize that healthcare managers can use managerial control mechanisms interactively, adopting them "not only as modules of feedback control to monitor the performance/results relationship but also as mechanisms of interaction for those involved in the organizational processes, to improve the learning capability of the entire organizational structure (Argyris and Schôn, 1978), to advance the prospects for innovation and assess the strategic investment opportunities from the innovation processes" (Demartini and Mella, 2014, p. 2). As already stressed, how feedback is given (is it timely, specific, constructive, etc..?) may change the budget acceptance and its perceived utility in healthcare organizations.
In terms of clinical performance, physicians' results highly depend on the source, duration timing and amount of feedback (Veloski et al., 2006). Beyond clinical outcomes, feedback is found to have a strong influence also over physicians sense of commitment towards the organization they work for. Macinati (2010) conducted an empirical research and found out that clinicians' commitment to organizational goals is positively influenced by "the use of the budget as a means to evaluate and reward clinicians' performance" (p. 435), activities which certainly imply feedback processes. Moreover, Mathauer and Imhoff (2006) argue that a working setting where recognition, feedback and participation are guaranteed contribute to increase health workers' perceptions of self-efficacy, in turn enhancing their motivation to success in the workplace.
In their study, also Bajwa et al. (2012) argue that feedback on health workers' performance enhances their level of job satisfaction. Moreover - they say - feedback is found to positively
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influence doctors' use of skills and perceptions of task significance, in turn improving clinicians' sense of job meaningfulness, work effectiveness and motivation. Other motivating factors are task identity, task significance autonomy, environment, job security and compensation. All factors are important to improve organizational commitment, but feedback "represents the factor with the highest motivation potential especially among the younger population" (p. 27). Physicians in particular among healthcare workers always strive to obtain positive feedback driven by the fear of losing respect by other colleagues (Bini, 2015). In this regard, how feedback is given and released dramatically affects clinicians' commitment. Indeed, in addition to the "standard" dimensions of the feedback process, the public release of sensitive data should be taken into account in the healthcare setting. However, in healthcare organizations, feedback is one of the primary levers in order to enhance professionals' expertise (Anguinis et
al., 2011) and the overall organization performance, both from a clinical and managerial
perspective: by learning from the best practices, professional can individuate the most effective and efficient solutions to adopt. Certainly - as Bini stresses - the actual adoption of these best practices calls for an engagement strategy focused on tools as educational interventions, audits and feedbacks performance data release (Epstein, 2010, as cited by Bini, 2015). However, as noticed by Audet et al. (2005), in order to set up an effective feedback system, organizations may invest resources on both quantity and quality of administrative data. In other words, the beneficial effects of feedback on health workers' motivation are not for free: in order to be reliable and effective, resources over the information system have to be invested. This holds also for the budgetary system.
Even if we did not find many budget specific considerations over the feedback area as far as healthcare setting is concerned, we can conclude that all in all the literature suggests that feedback over goals has a strong and positive impact on healthcare professionals' organizational commitment.
3.5 RESEARCH QUESTIONS
Even if health-care settings are non-profit organizations that produce services not for business purposes, it has been acknowledged that the effective and efficient use of resources is one of the main strategic objectives in order to maximize the output for all the stakeholders involved in the system (Abernethy et al., 2007). In this general framework, the budgeting system may
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become a crucial management control tool in order to commit workers to the organizational objectives. However, in the healthcare sector, performance management systems - the enablers of an effective and accepted budget system - often suffer from unique critical issues in that they aim to organize the activities of clinical professionals who, on the other hand, are characterized by a pronounced and well-established professional autonomy. One possible solution is to motivate medical professionals to use the budgetary system as an effective tool which belongs to both the managerial and clinical philosophy. How can we foster health workers' motivation to use the budget system not just as a mere administrative exercise but as a roadmap in their daily activities? We argue that, beyond budget contents, the process may make the difference in that it changes the utility of the system perceived by the workers. The pure and sterile cybernetic approach, typical of the budget system, cannot work in the healthcare sector (Hostfede, 1978). In this regard, other approaches based on organizational culture (Ouchi, 1979) and values (Simons, 1995) may be far more effective. However, the budget remains an essential tool to organize and coordinate employees' objectives in a complex organization. Therefore, when designing an organizational commitment strategy for clinical professionals, the budget system cannot be neglected and the engagement strategies based on it should be carefully structured. As the discussion suggests, the main aim is thus to shift the budget paradigm away from being a sterile cybernetic ritual towards the definition of a budget system which will be the basis for a shared language between the clinical and non-clinical worlds: in other words, budget should be transformed into an effective engagement tool.
In light of the literature analysed we identified two research questions to test in the scope of our discussion:
R1. Budget focused strategies positively moderates the relationship between overall organizational engagement strategies and organizational commitment.
R2. Budget utility as perceived by healthcare workers positively moderates the between overall organizational engagement strategies and budget focused strategies.
We expect both hypotheses to be confirmed by empirical evidence: if this is the case, also our research will suggest that in order to improve healthcare workers’ commitment towards organizational goals the way the budget process is lived and perceived by target owners is of
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paramount importance. Healthcare organizations should then strive to design the budget system as an accepted tool aimed at engaging and motivating workers.
27 4. EMPIRICAL EVIDENCE FROM THE TUSCAN HEALTHCARE SYSTEM
After presenting the main traits of the Italian National Health Service, this chapter will focus on the model used to test the empirical evidence, on the data used and on the obtained results. Finally, the results will be discussed in order to answer the stated research questions.
4.1 THE ITALIAN NATIONAL HEALTH SERVICE AND THE ROLE PLAYED BY THE BUDGETARY SYSTEM
The Italian National Health Service (NHS) is public and covers the entire population with universal coverage through general taxation (so called Beveridge model as opposed to the Bismark model (Musgrove, 2000)). The Italian NHS consists of three distinguished tiers (macro, meso and micro level): the central government is located at the top, the 21 regional authorities in the middle and the 265 health care organizations at the bottom. The central level is represented by the Ministry of Health and the Ministry of Finance: It guarantees the essential levels of care among the 21 regions and allocates the health care budget (almost 9.2% of GDP in 2014 according to the OECD health care data) gathered through the public taxation system to the regions according to a per capita principle, eventually adjusted by the age distribution of the population. Regions are highly autonomous thanks to the Constitutional amendment which in 2001 has significantly regionalized the Italian NHS. The regionalization of the Italian NHS has been viewed as the arrival point of a long series of reforms adopted since 1992 in response to New Public Management principles like as decentralization and the introduction of performance methods in public administrations. Indeed, nowadays regions autonomously decide their regional plans and programs; appoint healthcare organization managers; allocate the national budget within their regional system; can additionally fund their expenditures with
ad hoc regional taxes. Besides, as the new Millennium has arrived, regions gained more and
more fiscal autonomy and, at the same time, an increased financial responsibility (Fattore et
al., 2014; Ferrè et al., 2012). As stated by Nuti et al. (2016), "Italian regions now have the
political, administrative and financial responsibility for the provision of health care to their residents" (p. 4). In turn, also individual health care organizations (healthcare agencies and hospitals) have gained more autonomy, therefore causing huge cross-regional (and cross-town) differences in the health care services provided.
From an accounting perspective, health care organizations have traditionally rely on cash and commitment based budgeting, even if in recent times accrual-based financial and management accounting have been adopted (Macinati and Pessina, 2014).
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In this respect, management control systems play a double role. On the one hand, given the great geographical disparity among regions in terms of quality of services delivered and expenditures capacity, MCS may be used as a performance evaluation tool (Nuti, 2008). Of course, given the intrinsic nature of the health care sector, performance should be intended as a multifaceted construct, where not only financial performance is taken into account but also other key issues are analysed and assessed (e.g. the quality perceived by patients, how health care professionals evaluate the organizational internal climate, the health agency's capacity of reaching regional goals, etc). In this regard, MCS in general and the budgetary system in particular may individuate the best practices to spread among the other regional systems: if an organization is able to reach organizational objectives always successfully in terms of both efficacy and efficiency, this means that its regular procedures and practices are worthy to be brought to the attention of all healthcare professionals in all regions. Indeed, the spread of these best practices may dramatically enhance the overall Italian NHS performance. In this regard, the budgeting system may therefore be used as a benchmarking tool (Kelley and Hurst, 2006).
On the other hand, health care organizations need better financial conditions in order to gain even more autonomy to reach their clinical (and non-clinical) objectives (Macinati and Pessina, 2014). Under this perspective, financial results are deemed to be a key component of performance in that they make it possible to achieve all the other classes of goals. In this case, it is self-evident the pivotal role MCS and the budgeting system play.
In the Italian panorama, we have decided to focus on the Tuscan health care setting. The Tuscan case is very interesting in that it has adopted a hybrid governance model which combines the hierarchy and target model (also known as the command and control model because of the strong role of the regional performance management), the transparent public ranking (also known as the naming and shaming model because of its high levels of transparency) and the pay for performance model, even if applied only with regards to CEO's remuneration schemes (Nuti et al., 2016). Moreover, the Tuscan healthcare setting boasts a consolidated performance evaluation system which both "provide information to patients and organizations and help in identifying possible rooms for improvement" (Bini, 2015, p. 21). Given the consolidated use in Tuscany of PMSs, this research will therefore study healthcare professionals in this particular region.
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4.2 THE MODEL
To analyse the relationship between organizational commitment, general engagement strategies and budget specific engagement strategies, a hierarchical linear model was used. In the model, organizational commitment is the dependent variable and overall engagement strategy is the independent variable, while budget specific strategy and budget perceived utility are included in the model as moderator variables (see figure below). Given the hierarchical nature of the data (workers nested within hospitals) different specification of the model, namely fixed and random effect, were compared.
To explore the two models, that is random and fixed effect models, we used the Hausman test, which is substantially based on the difference between within-cluster and between-cluster coefficients. The fundamental distinction between fixed and random effects relies on "whether the unobserved individual effect embodies elements that are correlated with the regressors in the model, not whether these effects are stochastic or not" (Greene, 2008, p. 183). In the former case it makes therefore sense to use a fixed effect model, in the latter a multi-level model. In our case, Hausman test indicated that the random effect model was adequate: difference in organizations explains almost 10% of overall variability. Therefore, the hospital effects were modelled as random.
To test our hypotheses, we run the regression model twice. In the first model we focused on the relation organizational commitment – overall engagement strategy – budget specific engagement strategy, while in the second model we focused on the relationship overall engagement strategy – budget specific strategy – budget perceived utility. Both models include sex, age and professional role variables.
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Overall model
Overall model tested. Red arrows test the first relation (organizational commitment-overall engagement strategies-budget specific engagement strategies) while blue arrows the second one (overall engagement strategies-budget specific strategies-budget perceived utility)
Model I
First model tests the relationship between organizational commitment, overall engagement strategies and budget specific engagement strategies.
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where i = respondent
j = healthcare organization
𝑌𝑖𝑗 = organizational commitment of i employee in j organization
𝑥1𝑖𝑗 = overall engagement strategies as perceived by i employee in j organization
𝑥2𝑖𝑗 = budget specific engagement strategies as perceived by i employee in j organization
𝑥3𝑖𝑗 = control variables (age, sex, professional role) of i employee in j organization
uij = error term
Model II
Second model tests the relationship between overall engagement strategies, budget specific engagement strategies and budget perceived utility.
𝑌𝑖𝑗 = 𝛽0+ 𝛽1𝑥1𝑖𝑗+𝛽2𝑥2𝑖𝑗+𝛽1𝑥1𝑖𝑗∗ 𝛽2𝑥2𝑖𝑗+𝛽3𝑥3𝑖𝑗+ 𝑢𝑖𝑗
where i = respondent
j = healthcare organization
𝑌𝑖𝑗 = overall engagement strategies as perceived by i employee in j organization
𝑥1𝑖𝑗 = budget specific engagement strategies as perceived by i employee in j organization
𝑥2𝑖𝑗 = budget utility as perceived by i employee in j organization
𝑥3𝑖𝑗 = control variables (age, sex, professional role) of i employee in j organization
uij = error term
4.3 DATA
To test the hypotheses discussed at the end of the previous chapter we used a questionnaire sent out in 2017 both to managers (heads of departments) and regular employees (physicians, administrative staff, nurses, etc..). Even if the questionnaire has involved many regions in Italy,
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we decided to focus on Tuscany not only because of its long-standing tradition in performance measurement, but also and in particular because Tuscan response rate was the highest (40% of health workers took the questionnaire in Tuscany, while in the other regions the response rate was less than 30%).
The questionnaire, differentiated in its content between managers and employees, has been designed by the MeS Lab of the Sant'Anna School of Advanced Studies in order to investigate employees' perceptions of the internal climate within their job settings. For the sake of our research, we took into account the employees' questionnaire only for three main reasons: first of all, because of the great number of employees involved in comparison to heads of departments; secondly and foremost, because it is the middle management, as explained in the reverse pyramid figure discussed at the beginning of the dissertation (Bini, 2015), the one who is really responsible for patients' satisfaction (Haas et al., 2000) and, ultimately, quality of care in general (Grol et al., 1985); finally, it is interesting and innovative to analyse the voice of middle management since most studies focus on heads of departments (e.g. Vainieri et al., 2017).
In this section three pillars will be discussed: the questions chosen from the questionnaire and their description; the organizations involved in the research; the employees involved in the study.
Measures of motivation, participation and feedback
The MeS questionnaire is composed of 8 sections (my organization, working conditions, management, my job, budget, communication and information, training and some general closing questions) and 63 questions. The questionnaire has been carefully examined and validated by Pizzini and Furlan (2012).
Out of all the questions, only 12 items have been selected and used for the sake of this research. All questions are rated through a five points Likert scale, where 1 means 'I totally disagree with the above statement' and 5 'I totally agree with the above statement'. As discussed before, this research takes into account four main elements: organizational commitment, overall engagement strategies, budget specific engagement strategies and budget perceived utility. Here below are described the main components of these four elements.
