Inciting maintenance: Tiered institutional work during value-based payment reform in oncology.

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned.

Good organizational practices to encourage women high-performance coaches in sports.

Women play a vital role in professional sport on and off the field. Globally, the dearth of women high-performance coaches in sport is a concern. For example, in Australia women represent 15% of high-performance coaches. One reason could be due to the lack of knowledge on good organizational practices that encourage women in this role and the overwhelming knowledge of practices focused on barriers for women high-performance coaches. The purpose of our research was to determine what good organizational practices exist to attract, develop, and retain women as high-performance coaches in Australia. Using a qualitative research design, semi-structured interviews were conducted with two study groups that comprised 16 women high-performance coaches and 13 senior managers from five National Sport Organizations (NSOs) in Australia. Data analysis was guided by practices that influenced the attraction, development, and retention of women high-performance coaches. Practically, findings revealed 12 good organizational practices and 31 associated recommendations to assist senior managers from NSOs in their quest to encourage women high-performance coaches in their sport. Theoretically, our research "reverses the lens" of the Ecological Intersectional Model (EIM) at the organizational level whereby the focus turns to good organizational practices rather than barriers for women high-performance coaches.

Social Prescribing Nomenclature, Occupational Therapy and the Theory of Institutional Work: Creating, Maintaining and Disrupting Medical Dominance.

Social prescribing is a process of helping people to access non-medical activities and services which address health and wellbeing needs. The process is frequently (although not exclusively) initiated by primary health care professionals and often involves prescribing activities or initiatives provided by community and voluntary organizations. To occupational therapy, the links between activity, social-connectedness and health are clearly not new, although there are emerging international examples of social prescribing initiatives, and examples of newly developed roles, processes and funding opportunities, all of which are creating momentum behind the agenda.In this commentary, we draw upon the theory of Institutional Work to examine how the language of "prescription," and the purposive action of policy-makers and practitioners, is shaping thinking and action in relation to activity and health. Arguably, this language has helped to translate the recommendation of activity to meet a range of health needs in to an accessible and implementable concept. However, it has also potentially contributed to positioning the concept within a medical model of health, upholding medical dominance, and leaving occupational therapy on the margins of the debate.

Emotional labour as a vehicle of organisational change in maternity care: The case of Russian doulas' institutional work.

Sociological scholars of healthcare professions are becoming increasingly aware of the organisational dimension of professionalism, including how professionals as institutional actors are exposed to and influence organisational transformation. By tracing the ground-level professional efforts of Russian doulas-a caring profession that has been plunged into a reforming health system-in this article I explore how meaning-making activities and professionals' emotional labour build into and advance institutional changes in post-socialist maternity care. Drawing on qualitative research materials, I define three ways through which doulas' institutional efforts engage with emotions in clinical settings: (1) redefining emotional labour as a compound of maternity care; (2) grounding emotional labour in the context of reforming institutions; (3) using emotional labour to bridge discrepancies within organisational arrangements in healthcare. My research findings provide new insights into how marketisation influences professional care, as well as about caring professionalism in post-socialist maternity care. Attention to doulas' professional efforts allows for the affective transformation and inequality in the context of healthcare reforms to be analytically grasped. In particular, I trace how doulas' institutional agency embodied in emotional labour constructs the neo-liberal patient's identity.

Understanding the Microfoundations of Government-Civil Society Relations.

This article adds a much needed microlevel perspective to the literature on interactions between civil society organizations and governments. I argue that a microlevel perspective assists in making connections between two dominant streams in the literature on government-CSO relations: an empirical-analytical stream and a critical stream. It aims to better understand the interactions and relations, by analysing the institutional work done by CSOs' members. Adopting this approach puts CSO members in a more agentic position. Interactional processes are brought to the centre of analysis. The Dutch Community Sport Coach programme was used as a case to illustrate the usefulness of the approach. Through a one-year organizational ethnography, the article scrutinizes the way in which members of one CSO enact the organization's service delivery relationship with a municipality. Through a multidimensional perspective on agency, the analysis shows how individual CSO members act as embedded agents that assimilate a public logic into the dominant community logic. It further shows the CSO's members efforts and struggle to maintain their community logic. The article argues that an analysis of the microfoundations of government-civil society organization relations foregrounds the multivocality of the relationship as foundational.

Institutional work through empathic engagement.

A growing body of literature examines how actors engage with institutions and how they prompt institutional change and evolution. This article takes stock of this knowledge and contributes an affective dimension to the study of how institutional entrepreneurs achieve momentum and field-level impact. The article views institutional work as relational agency and conceptualises empathic engagement as a way for institutional entrepreneurs to relate affectively to other actors and induce cooperation. We demonstrate how empathic engagement by institutional entrepreneurs can nurture communities of practice that co-create change in institutional fields. Our argument hinges on the actors' affective investment and advances the less developed non-cognitive dimension of institutional work. By integrating empathic engagement into institutional entrepreneurship, we demonstrate how institutional entrepreneurs nurture their ability to engage and cooperate with others to diffuse particular values through institutional work. This integration focuses on the way of knowing generated through empathic engagement: the ability to bring about a consensus by creating frames of reference and identities that others are enchanted by and subscribe to, as opposed to using coercive mechanisms.

How do sharing organisations create and disrupt institutions? Towards a framework for institutional work in the sharing economy.

The sharing economy is a new form of resource distribution that is affecting traditional markets, cities and individuals, and challenging the prevalent regulatory frameworks, social norms and belief systems. While studies have examined some of its disruptive effects on institutional actors, there has been less focus on the ways in which sharing economy organisations work to create new or disrupt prevalent institutions. This study aims to fill this gap by 1) applying a framework for institutional work by Lawrence and Suddaby (2006) to help understand, map out and classify a variety of mechanisms for urban sharing organisations to engage in institutional creation and disruption, and by 2) testing and adjusting the framework to the context of the sharing economy. The analysis builds on empirical data from case studies, field observations and almost 70 interviews with representatives of urban sharing organisations and actors in their organisational field.

A falta de trabalho institucional e mudanças organizacionais incompletas em municípios brasileiros / La falta de trabajo institucional y cambios organizacionales incompletos en municipios brasileños / Lack of institutional work and organizational change failure in Brazilian local governments

Resumo Este artigo propõe um modelo para explicar falhas na adoção compulsória de novas práticas no ciclo de gestão financeira em municípios. Empiricamente, aplica-se o modelo à adoção de sistemas de controle interno (SCI) em municípios brasileiros. As evidências da análise qualitativa comparada (qualitative comparative analysis - QCA) em sete prefeituras mostram que, apesar de recursos humanos e de sistemas serem condição necessária, eles não são suficientes para a implementação das práticas de controle interno. O chamado capital institucional é uma condição sine qua non para a adoção de novas práticas de administração e controle financeiro em governos locais no Brasil. A adoção dessas reformas depende da atuação de uma rede de "atores com poder" que realizam trabalho institucional em prol das mudanças.

Resumen Este artículo propone un modelo para explicar fallas en la adopción obligatoria de nuevas prácticas en el ciclo de gestión financiera en municipios. Empíricamente, se aplica el modelo a la adopción de los sistemas de control interno en municipios brasileños. Las evidencias del análisis comparativo cualitativo (qualitative comparative analysis - QCA) en siete municipalidades demuestran que la existencia de recursos humanos y de sistemas son una condición necesaria, pero no suficiente para la implementación de las prácticas del control interno. El capital institucional es una condición sine qua non para la adopción de nuevas prácticas de gestión y control financiero en gobiernos locales en Brasil. La adopción de esas reformas depende del apoyo de varios "actores con poder" que realizan trabajo institucional en pro de las reformas.

Abstract This article proposes a theoretical framework to explain the failure of the compulsory adoption of new practices in the financial management cycle in local governments. The empirical analysis applies the framework to the control systems implementation in Brazilian municipalities. The findings of a qualitative comparative analysis applied to seven local governments show that despite human capabilities and information systems being a necessary condition, they are insufficient to deeply implement such internal control practices. Institutional capital is a condition sine qua non for the adoption of new practices on financial management and control in Brazilian local governments. The adoption of such reforms depends on an active network of powerful actors involved in institutional work supporting the changes.

Benefactor or burden: Exploring the professional identity of safety professionals.

INTRODUCTION: The professional identity of safety professionals is rife with unresolved contradictions and tensions. Are they advisor or instructor, native or independent, enforcer of rules or facilitator of front-line agency, and ultimately, a benefactor for safety or an organizational burden? Perhaps they believe that they are all of these. This study investigated professional identity through understanding what safety professionals believe about safety, their role within organizations, and their professional selves. Understanding the professional identity of safety professionals provides an important foundation for exploring their professional practice, and by extension, understanding organizational safety more broadly. METHOD: An embedded researcher interviewed 13 senior safety professionals within a single large organization. Data were analyzed using grounded theory methodology. The findings were related to a five-element professional identity model consisting of experiences, attributes, motives, beliefs, and values, and revealed deep tensions and contradictions. This research has implications for safety professionals, safety professional associations, safety educators, and organizations.

Discursively framing physicians as leaders: Institutional work to reconfigure medical professionalism.

Physicians are well-known for safeguarding medical professionalism by performing institutional work in their daily practices. However, this study shows how opinion-making physicians in strategic arenas (i.e. national professional bodies, conferences and high-impact journals) advocate to reform medical professionalism by discursively framing physicians as leaders. The aim of this article is to critically investigate the use of leadership discourse by these opinion-making physicians. By performing a discursive analysis of key documents produced in these strategic arenas and additional observations of national conferences, this article investigates how leadership discourse is used and to what purpose. The following key uses of medical leadership discourses were identified: (1) regaining the lead in medical professionalism, (2) disrupting 'old' professional values, and (3) constructing the 'modern' physician. The analysis reveals that physicians as 'leaders' are expected to become team-players that work across disciplinary and organizational boundaries to improve the quality and affordability of care. In comparison to management that is negatively associated with NPM reform, leadership discourse is linked to positive institutional change, such as decentralization and integration of care. Yet, it is unclear to what extent leadership discourses are actually incorporated on the work floor and to what effect. Future studies could therefore investigate the uptake of leadership discourses by rank and file physicians to investigate whether leadership discourses are used in restricting or empowering ways.

The institutional workers of biomedical science: Legitimizing academic entrepreneurship and obscuring conflicts of interest.

Given growing initiatives incentivizing academic researchers to engage in 'entrepreneurial' activities, this article examines how these academic entrepreneurs claim value in their entrepreneurial engagements, and navigate concerns related to conflicts of interest. Using data from qualitative interviews with twenty-four academic entrepreneurs in Canada, we show how these scientists value entrepreneurial activities for providing financial and intellectual resources to academic science, as well as for their potential to create impact through translation. Simultaneously, these scientists claimed to maintain academic norms of disinterested science and avoid conflicts of interest. Using theories of institutional work, we demonstrate how entrepreneurial scientists engage in processes of institutional change-through-maintenance, drawing on the maintenance of academic norms as institutional resources to legitimize entrepreneurial activities. As entrepreneurial scientists work to legitimize new zones of academic scientific practice, there is a need to carefully regulate and scrutinize these activities so that their potential harms do not become obscured.

Effects of EU harmonization policies on national public supervision of clinical trials: A dynamic cycle of institutional change and institutional work.

BACKGROUND: The EU Clinical Trials Directive (EUCTD) and the EU Clinical Trials Regulation aim to harmonize good clinical practice (GCP) of clinical trials across Member States. Using the Netherlands as a case study, this paper analyzes how endeavours to implement the EUCTD set in motion a dynamic process of institutional change and institutional work. This process lead to substantial differences between policy and actual practice; therefore, it is important to learn more about the implementation of harmonization policies. METHODS: Relevant documents, such as legal texts and previous research, were analyzed. Interviews were conducted with stakeholders in clinical trials and inspectors from (inter)national supervisory bodies (n=33), and Dutch Health Care Inspectorate inspections were observed (n=4). RESULTS: Dutch legislators' efforts to implement the EUCTD created a new level of governance in an already multilevel legislative framework. Institutional layering caused a complex and fragmented organizational structure in public supervision, leading to difficulties in achieving GCP. This instigated institutional work by actors, which set in motion further incremental institutional change, principally drift and conversion. CONCLUSIONS: Harmonization processes can create dynamic cycles between institutional change and institutional work, leading to significant divergence from the intended effects of legislation. If legislation intended to strengthen harmonization is not carefully implemented, it can become counterproductive to its aims.

Working with layers: The governance and regulation of healthcare quality in an institutionally layered system.

Institutional arrangements used to steer public policies have increasingly become layered. Inspired by the literature on institutional layering and institutional work, this paper aims to make a contribution to our understanding of institutional layering. We do so by studying an interesting case of layering: the Dutch hospital sector. We focus on the actors responsible for the internal governance (Board of Directors and Supervisory Boards) and the external regulation (the Healthcare Inspectorate) of hospitals. In the paper, we explore the institutional work of these actors, more specifically how institutional work results from and is influenced by institutional layering and how this in turn influences the institutional makeup of both healthcare organizations and their institutional context. Our approach allowed us to see that layering changes the activities of actors in the public sector, can be used to strengthen one's position but also presents actors with new struggles, which they in turn can try to overcome by relating and using the institutionally layered context. Layering and institutional work are therefore in continuous interaction. Combining institutional layering with a focus on the lived experiences of actors and their institutional work makes it possible to move into the layered arrangement and better understand its consequences.