Decoupling in the health‐care sector is a highly problematic phenomenon that easily leads to dramatic failures in strategy implementation. Although decoupling is addressed frequently at the organizational level, there exists extremely poor evidence of its presence at the federal/regional level. This study provides an investigation on the implementation of Italy's directive on the re‐organization of regional health‐care systems' networks based on breast units, with the intent of detecting different levels of compliance across regions and possible decoupling phenomena. Nonparametric tests are carried out to assess the gaps between formal and concrete compliance to the national directive across regions. Results suggest that decoupling occurs at the regional level, but formal compliance positively affects concrete compliance in the long term. Implications for policymakers concern their awareness of possible discrepancies between formal compliance to their directives and concrete changes in the way health‐care services are managed, as well as a strategic understanding of how these are doomed to be mitigated in the long run. Such awareness should affect the ability of policymakers to adapt and interpret performance measurement systems accordingly.