The complex power dynamics within a health care institution during the 15th and 18th centuries. The case of the Great and New Hospital of Palermo

Starting from the Middle Age, the need for discipline and adequate regulation and control, has required the most important hospitals to produce special sets of rules, named Chapters, which guaranteed the correct, orderly performance of all administrative and assistance activities of the institution. Since its origins in 1431, the “Grande Ospedale e Nuovo” (GON) (today, the Benfratelli Hospital in Palermo) has been equipped with a set of regulation (Chapters). In this work, the Chapters created in 1431, 1442, 1610, 1624 and 1722 are examined as they are rules concerning accounting and accountability practices, referring to both financial and non-financial information, inserted in a complex of tools, care practices and other aspects of GON life. The path towards the profound transformation of GON, as emerged from the analysis of the five manuscripts, can be linked to the principal moments of the institution’s administrative changes. Although it may appear to be an apparatus of the State, it also elucidates how accounting demonstrates that the power dynamic is actually more complex as it is also linked to the control exerted by the Pope, the Archbishop and the Benedictines and Capuchins. Along this line, accounting and accountability practices are profoundly implicated in the power relations which emerged from social life. In this sense, they are deemed as not being neutral, but can be interpreted as reflecting and serving certain economic or political interests, having the potential for documenting not only the financial aspects of organizational activities, but also their “cultural dimension. Aim of the work: Through the analysis of the GON evolution, as reflected into the different versions of the five analyzed Chapters, this study seeks to sheds light on the intricate construction of the modern concept of hospital where each action is well identified and a clear separation between management function and health care services is effected. Moreover, this research allows us to an understanding of the critical role of hospital accounting practices as strictly connected to public and private supports. By stressing the significance of the rigorous monitoring process of each moment and of each action the research allows the wide comprehension of the reasons of the increasing over time of rules aimed to the administration and conduction of the Hospital. Methodological approach: The paper is based upon primary sources gathered from the Palermo State Archives; the book Nuovi Capitoli per lo Buon Governo dell'Ospedale Grande, (1725) preserved in the Interdepartmental Centre of Humanistic Disciplines Library, University of Palermo; The Biblioteca Comunale di Palermo (BCP) manuscripts. Their interpretation has been guided by the literature for the understanding of the role of accounting in linking accountability and administrative process. Main findings: The findings of this study provide the opportunity to examine how accounting plays an active role in the construction of an organizational order. Accounting is not deemed as an autonomous phenomenon, but other social, political and economic factors are seen as being able to provide bases for accounting change, often playing a significant role in influencing the course of its transformation, providing bases to how change concept is helpful to the understanding of accounting as involved in such wider process of transformation. Originality: The present study provides an exceptional means to expose the contributions of a complex power dynamic relationship, related to a State hospital that even if may appears to be controlled by the State, it results that other external forces are involved in it, each one of it exert some control, as Pope, Archbishop, King, Senate and Benedictines. Furthermore, analysis of the GON evolution along the more significant phases of its long life leads to the understanding of the modern version of hospital as characterized by a clear parting of each duty and by management functions that are consistently separated by the health care services.