Putting the patient first? The story of a decoupled hospital management quality initiative

This paper depicts the progress of a hospital management quality pilot project through the lens of institutional theory. Nine hospital departments were chosen to change their management control system from a strict top-down productivity focus to a locally developed performance measurement system based on a patient focus. Thus, the management control system was changed with the aim of enhancing the social impact of the provided hospital services by integrating a patient focus. The paper portrays a three-year evolution through management narratives. Findings evidence initial embracement of the project followed by gradual operational management discouragement due to external productivity pressures and internal data issues. Despite these challenges, the regional management highlighted the project as a success and expanded it to the remaining departments. Thus, we find that the project became decoupled rather than institutionalized due to a sustained productivity logic. Through the lens of institutional theory, we argue that a decoupling of the patient focused project happens because of a surprisingly strong institutionalized productivity logic. We suggest that in this context of strong coupling of previous systems, organizations may paradoxically engage in decoupling practices that are intended to support their professional core practices but instead protect the administrative logic of efficiency and productivity.