title: Achieving and sustaining profound institutional change in healthcare: case study using neo-institutional theory.
abstract: Change efforts in healthcare sometimes have an ambitious, whole-system remit and seek to achieve fundamental changes in norms and organisational culture rather than (or as well as) restructuring the service. Long-term evaluation of such initiatives is rarely undertaken. We report a secondary analysis of data from an evaluation of a profound institutional change effort in London, England, using a mixed-method longitudinal case study design. The service had received £15 million modernisation funding in 2004, covering multiple organisations and sectors and overseen by a bespoke management and governance infrastructure that was dismantled in 2008. In 2010-11, we gathered data (activity statistics, documents, interviews, questionnaires, site visits) and compared these with data from 2003 to 2008. Data analysis was informed by neo-institutional theory, which considers organisational change as resulting from the material-resource environment and three 'institutional pillars' (regulative, normative and cultural-cognitive), enacted and reproduced via the identities, values and activities of human actors. Explaining the long-term fortunes of the different components of the original programme and their continuing adaptation to a changing context required attention to all three of Scott's pillars and to the interplay between macro institutional structures and embedded human agency. The paper illustrates how neo-institutional theory (which is typically used by academics to theorise macro-level changes in institutional structures over time) can also be applied at a more meso level to inform an empirical analysis of how healthcare organisations achieve change and what helps or hinders efforts to sustain those changes.
authors: Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, London, UK.
authors: Fraser
authors: F
authors: Macfarlane
authors: Cathy
authors: C
authors: Barton-Sweeney
authors: Fran
authors: F
authors: Woodard
authors: Trisha
authors: T
authors: Greenhalgh
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D006801:Humans; D008131:London; D017146:Models, Organizational; D009936:Organizational Innovation; D013222:State Medicine / Q000458:organization & administration*