{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T12:09:13Z","timestamp":1773922153406,"version":"3.50.1"},"reference-count":30,"publisher":"SAGE Publications","issue":"2","license":[{"start":{"date-parts":[[2015,12,17]],"date-time":"2015-12-17T00:00:00Z","timestamp":1450310400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Health Serv Res Policy"],"published-print":{"date-parts":[[2016,4]]},"abstract":"<jats:sec><jats:title>Objectives<\/jats:title><jats:p> Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands. <\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p> An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals. <\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p> How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures. <\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p> The development of hospital leaders\u2019 skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required. <\/jats:p><\/jats:sec>","DOI":"10.1177\/1355819615622655","type":"journal-article","created":{"date-parts":[[2015,12,19]],"date-time":"2015-12-19T01:29:33Z","timestamp":1450488573000},"page":"109-117","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":36,"title":["Using institutional theory to analyse hospital responses to external demands for finance and quality in five European countries"],"prefix":"10.1177","volume":"21","author":[{"given":"Susan","family":"Burnett","sequence":"first","affiliation":[{"name":"Researcher, Department of Surgery, Faculty of Medicine, Centre for Patient Safety and Service Quality, Imperial College London, UK"}]},{"given":"Peter","family":"Mendel","sequence":"additional","affiliation":[{"name":"Senior Sociologist, Rand Corporation, Santa Monica, CA, USA"}]},{"given":"Francisco","family":"Nunes","sequence":"additional","affiliation":[{"name":"Assistant Professor of Human Resources and Organizational Behaviour, ISCTE, Lisbon University Institute, Portugal"}]},{"given":"Siri","family":"Wiig","sequence":"additional","affiliation":[{"name":"Professor of Quality and Safety in Healthcare Systems, Department of Health Studies, University of Stavanger, Norway"}]},{"given":"Hester","family":"van den Bovenkamp","sequence":"additional","affiliation":[{"name":"Associate Professor of Public Administration in Health Care, Institute of Health Policy & Management, Erasmus University Rotterdam, The Netherlands"}]},{"given":"Anette","family":"Karltun","sequence":"additional","affiliation":[{"name":"Assistant Professor, The J\u00f6nk\u00f6ping Academy for Improvement of Health and Welfare, Sweden"}]},{"given":"Glenn","family":"Robert","sequence":"additional","affiliation":[{"name":"Professor of Healthcare Quality & Innovation, Florence Nightingale Faculty of Nursing and Midwifery, King\u2019s College London, UK"}]},{"given":"Janet","family":"Anderson","sequence":"additional","affiliation":[{"name":"Senior Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King\u2019s College London, UK"}]},{"given":"Charles","family":"Vincent","sequence":"additional","affiliation":[{"name":"Professor of Psychology, Department of Experimental Psychology, Oxford University, UK"}]},{"given":"Naomi","family":"Fulop","sequence":"additional","affiliation":[{"name":"Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, UK"}]}],"member":"179","published-online":{"date-parts":[[2015,12,17]]},"reference":[{"key":"bibr1-1355819615622655","unstructured":"HOPE. The crisis, hospitals and healthcare. Belgium: European Hospital and Healthcare Federation, 2011."},{"key":"bibr2-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.26.6.1622"},{"key":"bibr3-1355819615622655","unstructured":"Scott WR. Institutional theory. In: Ritzer G (ed.) Encyclopedia of social theory. Vol. 4. Thousand Oaks, CA: Sage, 2004, pp.408\u2013414."},{"key":"bibr4-1355819615622655","doi-asserted-by":"crossref","unstructured":"Oliver C. Strategic responses to institutional processes. Acad Manag Rev 1991; 16: 145\u2013179.","DOI":"10.5465\/amr.1991.4279002"},{"key":"bibr5-1355819615622655","volume-title":"Does improving quality save money. A review of evidence of which improvements to quality reduce costs to health service providers","author":"\u00d8vretveit J","year":"2009"},{"key":"bibr6-1355819615622655","volume-title":"Quality improvement made simple","author":"The Health Foundation","year":"2013","edition":"2"},{"key":"bibr7-1355819615622655","unstructured":"Boaden R, Harvey G, Moxham C, et\u00a0al. Quality improvement: theory and practice in healthcare. London: NHS Institute for Innovation and Improvement, 2008."},{"key":"bibr8-1355819615622655","doi-asserted-by":"crossref","unstructured":"Bate P, Mendel P and Robert G. Organizing for quality: the improvement journeys of leading hospitals in Europe and the United States. Milton Keynes: Radcliffe Publishing, 2008.","DOI":"10.1201\/b20730"},{"key":"bibr9-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)61850-9"},{"key":"bibr10-1355819615622655","unstructured":"Scott WR. Institutional change and healthcare organizations: from professional dominance to managed care. Chicago: University of Chicago Press, 2000."},{"key":"bibr11-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.soc.25.1.441"},{"key":"bibr12-1355819615622655","doi-asserted-by":"crossref","unstructured":"Kraatz MS and Block ES. Organizational implications of institutional pluralism. In: Greenwood R, Oliver C, Sahlin K and Suddaby R (eds) The Sage handbook of organizational institutionalism. Thousand Oaks, CA: Sage Publications, 2008, pp. 243\u2013275, 840.","DOI":"10.4135\/9781849200387.n10"},{"key":"bibr13-1355819615622655","doi-asserted-by":"publisher","DOI":"10.5465\/amr.1996.9704071862"},{"key":"bibr14-1355819615622655","doi-asserted-by":"publisher","DOI":"10.5465\/AMR.2010.51142368"},{"key":"bibr15-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-11-285"},{"key":"bibr16-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1017\/S0003055404001182"},{"key":"bibr17-1355819615622655","unstructured":"Yin RK. Case study research: design and methods. Thousand Oaks, CA: Sage Publications, 2014."},{"key":"bibr18-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzs079"},{"key":"bibr19-1355819615622655","doi-asserted-by":"crossref","unstructured":"Glaser B and Strauss A. The discovery grounded theory: strategies for qualitative inquiry. Chicago: Aldin, p.1967.","DOI":"10.1097\/00006199-196807000-00014"},{"key":"bibr20-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.1.3.267"},{"key":"bibr21-1355819615622655","unstructured":"Gro\u00dfe-Tebbe S and Figueras J. Snapshots of health systems. Ministry of Social Affairs and Health, 2005."},{"key":"bibr22-1355819615622655","unstructured":"Glaser BG and Strauss AL. The discovery of grounded theory: strategies for qualitative research. Piscataway, NJ: Transaction Publishers, 2009."},{"key":"bibr23-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1002\/smj.701"},{"key":"bibr24-1355819615622655","volume":"13","author":"Aase K","year":"2009","journal-title":"Saf Sci Mon"},{"key":"bibr25-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1177\/0170840605057670"},{"key":"bibr26-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2008.030759"},{"key":"bibr27-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1177\/1077558708317802"},{"key":"bibr28-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/9.1.69"},{"key":"bibr29-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2011.0076"},{"key":"bibr30-1355819615622655","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs.2010.046490"}],"container-title":["Journal of Health Services Research &amp; Policy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1355819615622655","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/1355819615622655","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1355819615622655","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,3]],"date-time":"2025-03-03T11:14:04Z","timestamp":1741000444000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/1355819615622655"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2015,12,17]]},"references-count":30,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2016,4]]}},"alternative-id":["10.1177\/1355819615622655"],"URL":"https:\/\/doi.org\/10.1177\/1355819615622655","relation":{},"ISSN":["1355-8196","1758-1060"],"issn-type":[{"value":"1355-8196","type":"print"},{"value":"1758-1060","type":"electronic"}],"subject":[],"published":{"date-parts":[[2015,12,17]]}}}