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Background  The culture of New Public Management has promoted the diffusion of strategic management tools throughout Public Healthcare Organisations (PHOs). There is consensus that better strategic planning tools are required to achieve higher levels of organisational performance. This paper provides evidence and understanding of the emergent uses and scope of strategic planning in PHOs, in order to answer three research questions: (i) has the New Public Management approach changed the organisational culture of PHOs in terms of how they adopt, diffuse, and use strategic planning documents? (ii) how coherent are strategic planning documents in PHOs? and (iii) what are the main purposes of strategic documents in PHOs?    Methods  An analysis was carried out in three Italian Local Health Authorities. We analysed the number and types of formal strategic documents adopted between 2004 and 2012, evaluating their degree of coherence and coordination, their hierarchy, their degree of disclosure, and the consistency of their strategic goals. A content analysis was performed to investigate overlap in terms of content and focus, and a qualitative analysis was carried out to study and represent the relationships between documents.    Results  The analysis showed that a rich set of strategic documents were adopted by each PHO. However, these are often uncoordinated and overlap in terms of content. They adopt different language and formats for various stakeholders. The presence of diverse external drivers may explain the divergent focus, priorities and inconsistent goals in the strategic documents. This planning complexity makes it difficult to determine how the overall goals and mission of an organisation are defined and made visible.    Conclusions  The evidence suggests that PHOs use a considerable number of strategic documents. However, they employ no clear or explicit overarching strategy currently, and strategic planning appears to be externally oriented. All the documents communicate similar topics to different stakeholders, although they use different language to answer to the different expectations of each stakeholder. Therefore, strategic planning and plans seem to be driven by neo-institutional approaches, as they are means to build consensus and negotiate ground for strategic actions, rather than means to identify strategic choices and priorities.

Decoupling the use and meaning of strategic plans in public healthcare