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The aim of the paper is to trace the history and development of performance measurement and management systems in the Italian National Health System (INHS), to identify their key characteristics, and to provide a critical assessment of their implementation.

A combination of literature review, action‐research and fieldwork conducted over a ten‐year period in several Italian health care organizations.

Performance management has grown considerably in the INHS over the last 15 years. Explanations for this growth include normative, coercive and mimetic isomorphism, the introduction of quasi‐markets, the adoption of DRGs, an increased focus on clinical governance and innovative practices in human resource management.

The paper shows how performance management has been implemented in the INHS and why it can still be considered a “work in progress”.

The introduction of performance management systems has stimulated greater accountability and promoted a more cost conscious culture in healthcare organizations. Nevertheless, there are many problems that remain to be solved if performance management arrangements are to deliver the desired improvements in performance.

The paper advocates the need for reduced isolationism and increased international comparison with concomitant evaluative effort.

The purpose of this paper is to account for a ten-year experience with the European Foundation for Quality Management (EFQM) Excellence Model implemented in the Trento Healthcare Trust.

Since 2000, the EFQM Excellence Model provided an overarching framework to streamline business process governance, to support and improve its enablers and results. From 2000 to 2009, staff performed four internal (self) and four external EFQM-based assessments that provided guidance for an integrated management system. Over the years, key controls and assurances improved service quality through business planning, learning and practice cycles.

Rising assessment ratings and improving results characterized the journey. The average self-assessment score (on a 1,000 points scale) was 290 in 2001, which increased to 610 in 2008. Since 2006, the Trust has been Recognized for Excellence (four stars). The organization improved significantly on customer satisfaction, people results and key service delivery and outcomes.

The EFQM Model can act as an effective tool to meet governance demands and promote system-level results. The approach to integrated governance discussed here may support similar change processes in comparable organizations.

The paper describes a unique experience when implementing EFQM within a large Italian healthcare system, which had a broader reach and lasted longer than any experience in Italian healthcare.