Strategic management in hospitals: Tensions between the managerial and institutional lens.
| Autor | Pascuci, Lucilaine Maria |
| Cargo | Report |
Abstract
The relationship between organizations and their environments has been object of study by scholars of the theory of organizations and in discussions concerning organizational strategy. When these perspectives come together, two sets of different but overlapping forces in the strategy formation process are highlighted. The purpose of this study is to analyze how strategic management contributed to reducing tensions derived from managerial and institutional logics in philanthropic hospitals. It is a comparative case study, with a multi-method approach. The data were examined using narrative and document analysis techniques. The analysis indicated that integrating organizational-managerialist and institutional perspectives raises continuous tensions within organizations with a direct impact on managerial decisions, strategic actions and performance. The strategic management approach should be sensitive enough to recognize and reduce these tensions and find ways to integrate them more effectively. This effort requires a combination of strong leadership skills and appropriate managerial tools. Flexibility, adaptability, creativity and informal interactions should be the basis of any strategic initiatives. Daring and innovation of the hospitals-more than acquiescence-are essential to their social and financial sustainability.
Key words: strategic management; institutionalism; managerialism; tensions; hospitals.
Introduction
Hospitals can be seen as social organizations as well as institutions with an increasingly important role to society (Etzioni, 1964). As organizations specializing in providing essential health services, learning and research centers, there has been growing criticism of the quality of their services and the cost to patients and the state (Correia, 2012). Critical factors are today challenging hospital manager like the high operational costs, internal inefficiencies and growing demand for diversified (Porter & Teinsberg, 2006).
As institutions, hospitals have a social mission to fulfill their goals by providing quality services to the needy when required. How well their institutional and organizational mission (King, 2015) is accomplished determines their legitimacy in the eyes of the community. In this context, multiple stakeholders and variables in the relationship between hospitals and their environments have a significant impact on the success of the strategies they develop (Jarzabkowski & Fenton, 2006; Meyer, Pascuci, & Mamedio, 2016).
The relationship between organizations and their environments was one of the first concerns in the Theory of Organizations and the debate on organizational strategy (Greenwood, Hinings, & Whetten, 2014). Different approaches have offered explanations regarding this relationship. From the three main approaches highlighted by Wilson (1992), the one that guides this study has to do with understanding the environment as the result of objective variables. However, the relationship between organization and environment occurs through the interpretation of these variables by managers and members of the organization, where elements of cognition and interpretation become highly relevant (Binder, 2007; Greenwood, Raynard, Kodeih, Michelotta, & Lounsbury, 2011; Hinings & Greenwood, 1988; Oliver, 1991).
In recent years, Brazilian hospitals have changed their image from a welfare organization to a professional organization (Meyer et al., 2016). However, in this process, professionalization has been translated predominantly as enhancing financial performance, from the adoption of management methodologies from companies operating in the market (managerialist methodologies) (French & Grey, 1996; Locke & Spender, 2011), focusing mainly on efficiency and profitability. Nevertheless, these philanthropic institutions are subject to regulations and face the challenge of fulfilling of their institutional mission while achieving financial sustainability (Meyer, Pascuci, & Murphy, 2010; Meyer et al., 2016).
Managers practicing strategic management face a twofold challenge: the organizational complexity of hospitals and learning how to transform intentions into actions and meaningful outcomes with effectiveness and legitimacy while remaining committed to the organization's core values and beliefs (King, 2015). Strategic practice occurs in an interdependent way based on cooperation and interrelationships of its elements in an environment that is neither inert nor stable, and far less predictable. As loosely coupled systems (Orton & Weick, 1990), professional (Mintzberg, 1994) and pluralistic (Jarzabkowski & Fenton, 2006) organizations' strategic decisions and practices within hospitals have strong political connotations and their results depend on a complex interaction of top management team (TMT) and health professionals throughout the organization. These characteristics strengthen the importance of elements such as interpretation of reality, improvisation and learning (McDaniel, 2007).
In that context, the purpose of our study is to analyze the association between managerial and institutional logics and the strategic management in hospitals as pluralistic organizations. More specifically, this study seeks to answer the following research question: how did strategic management contribute to reducing tensions derived from managerial and institutional logics? To do so, we identified the main tensions resulting from the conflict of managerial and institutional logics and their implications in the strategic management of the hospitals.
Our perspective in this paper is neither rationalistic (based only on isolated organizational choices) nor strictly contingencialist (advocating a direct influence of the environment on organizations). Instead, we propose a balanced approach that combines the rationale that guides cognition and strategic actions, and the institutional logics that are unfolded recursively or actualized through strategic practices.
Considering the complexity and plurality of their organizational and environmental context, we can expect specific arrangements of managerial and institutional attributes operating in the strategic management of hospitals, not only due to their diversity but also to the ambiguity of their objectives, their stakeholders' beliefs and interests (Binder, 2007; Chandler & Hwang, 2015; Greenwood et al., 2011).
This paper contributes to the field by identifying and examining tensions derived from managerial and institutional approaches based on the strategic management practices experienced by philanthropic Brazilian hospitals inserted in a dynamic and sometimes unpredictable environment. This study investigates what went right and wrong in the adoption of managerialist practices in hospitals, seeking to demonstrate how managerial and institutional logics can achieve a balance in the management of social institutions such as hospitals.
Organization, Strategies and the Environment
Wilson (1992) highlights three main approaches to understanding the relationship between organizations and their environments. The first identifies the environment as an objective set of variables external to the organization to which the organization needs to adapt in order to be successful. The second stresses that the organizational environment continues to be understood as a set of objective variables. However, the relationship between organization and environment occurs through the interpretation of these variables by the managers and members of the organization, with emphasis on the elements of cognition and interpretation (see also Hinings & Greenwood, 1988; Lieberman & Asaba, 2006; Oliver, 1991; Pache & Santos, 2010). The third approach views the environment as a product of organizational processes. In this sense, the environment tends to be understood as a construct or as socially or cognitively enacted by the members of the organization (Weick, 1979).
For some time now, the relationship between organizations and their environments has been studied by scholars of organization theory and been the object of discussions concerning organizational strategy (Andersen, 2004; Porter, 1980). The junction of these analysis perspectives has resulted in two sets of different but overlapping forces in management, especially in strategy development and practices.
On the one hand, there is a set of rationalist organizational forces that concentrate on organizational performance; on the other, there is a set of institutional forces in which the environmental element is predominant. Although these are not the only explanatory elements of the strategy formation process, it is recognized that their implications challenge the transformation of intentions into actions. After all, being institutionally embedded (Greenwood et al., 2014; Peng, Sun, Pinkhan, & Chen, 2009), the strategic decisions of agents are influenced not only by results from a purely economic viewpoint but also by aspects perceived as socially appropriate (Ang, Benischke, & Doh, 2015; Lieberman & Asaba, 2006).
The integration of strategic management and institutional theories introduces a challenge through its different conception of human agency (Battilana & Leca, 2009). While strategic management theory assumes the existence of a high degree of human agency, in part of the institutional theory agency emerges, or is constrained or constituted by, environmental (cognitive, normative or legal) forces (Scott, 2001; Walker, Schlosser, & Deephouse, 2014). One way of conciliating these different visions, proposed by Battilana and Leca (2009), is the adoption of a relational vision of human agency.
This challenge must not be seen as a theoretical contradiction, as institutional theory has increased the investigation of agency as a decisive explanation when it comes to understanding engagement in institutional entrepreneurship and institutional work (Lawrence, Suddaby, & Leca, 2011), generating...
Para continuar a ler
PEÇA SUA AVALIAÇÃOCOPYRIGHT GALE, Cengage Learning. All rights reserved.
