title: Using institutional theory to analyse hospital responses to external demands for finance and quality in five European countries.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  The development of hospital leaders' 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.
authors.affiliation: Researcher, Department of Surgery, Faculty of Medicine, Centre for Patient Safety and Service Quality, Imperial College London, UK s.burnett@imperial.ac.uk.
authors.forename: Susan
authors.initials: S
authors.lastname: Burnett
authors.affiliation: Senior Sociologist, Rand Corporation, Santa Monica, CA, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Mendel
authors.affiliation: Assistant Professor of Human Resources and Organizational Behaviour, ISCTE, Lisbon University Institute, Portugal.
authors.forename: Francisco
authors.initials: F
authors.lastname: Nunes
authors.affiliation: Professor of Quality and Safety in Healthcare Systems, Department of Health Studies, University of Stavanger, Norway.
authors.forename: Siri
authors.initials: S
authors.lastname: Wiig
authors.affiliation: Associate Professor of Public Administration in Health Care, Institute of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
authors.forename: Hester
authors.initials: H
authors.lastname: van den Bovenkamp
authors.affiliation: Assistant Professor, The Jönköping Academy for Improvement of Health and Welfare, Sweden.
authors.forename: Anette
authors.initials: A
authors.lastname: Karltun
authors.affiliation: Professor of Healthcare Quality & Innovation, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, UK.
authors.forename: Glenn
authors.initials: G
authors.lastname: Robert
authors.affiliation: Senior Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, UK.
authors.forename: Janet
authors.initials: J
authors.lastname: Anderson
authors.affiliation: Professor of Psychology, Department of Experimental Psychology, Oxford University, UK.
authors.forename: Charles
authors.initials: C
authors.lastname: Vincent
authors.affiliation: Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, UK.
authors.forename: Naomi
authors.initials: N
authors.lastname: Fulop
mesh_terms: D003363:Cost Control / Q000458:organization & administration; D003469:Culture; D005060:Europe; D006302:Health Services Research; D006739:Hospital Administration / Q000191:economics* / Q000379:methods*; D006801:Humans; D007857:Leadership; D057766:Policy; D011057:Politics; D011361:Professional Competence; D011787:Quality of Health Care / Q000191:economics / Q000458:organization & administration*
keywords: finance; health care; institutional theory; quality