Selective (De)coupling and Change in Clinical Outcomes

Abstract

Through an in-depth longitudinal study of hospitals’ implementation of quality improvement initiatives within a single jurisdiction, I build on previous empirical findings of heterogenous organizational responses to common institutional pressures. Yet, rather than honing the causes of this heterogeneity, I examine its relationship to desired outcomes. I use Fuzzy-set Qualitative Comparative Analysis (Fs/QCA) to uncover intended and unintended consequences of hospitals’ heterogenous responses and theorize on why some configurations are associated with improved or worsened clinical outcomes. Findings suggest that management and healthcare scholars ought to pay greater attention to the subversive and superficial nature of some responses, as these are associated with a decline in clinical outcomes. Indeed, scholars have recognized that: “In fragmented and rationalized environments, organizations seek to respond to a greater number of external stakeholders; adapting to these external pressures can generate both internal complexity and inconsistency (Bromley & Powell, 2012, p. 20).” I find that coupling to two conflicting pressures, such as pressures to reduce costs while improving the quality of clinical services, creates internal inconsistencies which results in dynamics of subversion. In contrast, implementing clinical standards in the absence of an ambition to improve clinical services leads to the superficial implementation of these standards.