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The current paper addresses the complex issue of accountability by focusing on Italian public hospitals and teaching hospitals; it aims to analyze Italian health care organizations' strategies for responding to the pressure generated by regulations. In particular, in the last few years, Italian hospitals and teaching hospitals have been obliged to implement or improve their accountability instruments in response to a new regulation (known as the Brunetta reform, Legislative Decree number 150/2009). The Legislative Decree aims to measure and assess the results of each public administration unit in terms of efficiency of the human resources, satisfaction level of the final users, and transparency of its action. Despite the initial consensus on the necessity to make the decision process in health care visible and transparent, health care organizations find it difficult to demonstrate accountability. The present paper summarizes the evidence on the degree of compliance to the reform requirements and will allow an in-depth understanding of Italian health organizations' attitudes toward accountability. This study will help policymakers understand the degree of acceptance and application of the new reforms and assess whether the law/regulations may be effective drivers for disseminating a culture of transparency and accountability.

Accountability, Italian style: how to reply to government pressure?