گزینه های طراحی سازمانی در پاسخ به اصلاحات بخش دولتی: مطالعه موردی شبکه های لازم الاجرای بیمارستانی

In this study we investigate the design and control of public sector networks formed by government mandate. Specifically, we analyse how a range of antecedent factors influence the extent to which organisations within such networks effectively collaborate to unify their efforts. We examine the role of both formal and informal controls in promoting and co-ordinating activity and managing appropriation concerns among organisations of the network. We address these issues in the context of health sector reforms in Victoria, Australia, that resulted in the amalgamation of metropolitan hospitals into a number of hospital networks. While the reforms determined the particular aggregation of hospitals, management retained discretion as to the organisation and control of activity among hospitals of the network. We draw on Oliver's (1991) predictive model of strategic responses to institutional mandates to analyse how efficiency and legitimacy concerns, the influence of external constituents, and consistency between institutional and organisational goals influence resultant structural and control choices in three of these hospital networks. Specifically, we examine the extent to which structural and control attributes promote the integration of activity within networks by analysing the delegation and partitioning of decision rights, and the design and use of performance measurement systems, integrative liaison devices, and standard operating procedures. We also consider the implications of integration for network performance. In our empirical analysis of three hospital networks we observe tension in network design relating to the achievement of efficiency and legitimacy imperatives that underpin the mandate to form hospital networks. The networks differ in their potential to generate efficiency and legitimacy gains from collaboration, their commitment to the ideals underlying the institutional mandate, and their willingness to pursue effective collaboration in light of the influence of other external constituents. In turn they adopt structural and control system designs that reflect different levels of clinical activity integration, and different degrees of substantive acquiescence to the institutional mandate to collaborate.

The management of economic activity relies increasingly on various forms of collaboration between organisations, such as joint ventures, partnerships, strategic alliances, networks and co-operative inter-firm relationships (Anderson and Sedatole, 2001). The management accounting and control literature explores control problems and solutions in these hybrid forms of organisation. However, our understanding of these issues to date is constrained largely to the study of vertical inter-firm (supply chain) relationships in private sector settings (Caglio and Ditillo, 2008 and van der Meer-Kooistra and Scapens, 2008). In the public sector, collaboration between organisations is often the result of reform agendas introduced in an attempt to improve the efficiency and effectiveness of service delivery (Brown, 2000, Herzlinger, 1997, Lega, 2005, McMurchie, 2000, Reddy, 2002 and Scott, 2005). The management and control requirements of such collaborations are likely to differ significantly to those observed in the private sector, given the highly institutionalised context in which these organisations operate and given that collaboration is typically horizontal rather than vertical in nature. In this paper we investigate the design of mandated public sector networks. We undertake a case study of metropolitan hospital networks3 in Victoria, Australia, created as part of a series of reforms of health care sector activities. The central public funding authority in this setting initiated the formation of hospital networks in the expectation this would further efficiency and effectiveness imperatives. While the assignment of hospitals to networks was mandated, network management retained full discretion as to the nature of collaboration between hospitals. We draw on Oliver's (1991) framework of strategic responses to institutional processes to interpret observed network designs. We investigate the extent and form of integration within hospital networks and analyse concomitant control choices as well as the implications of these design choices for network performance. This study contributes to the literature in a number of ways. First, we consider the design of public sector hospital networks as a strategic response to a mandate to form collaborative relationships. We know little of the factors that influence design choice when collaboration is imposed, rather than voluntary. The use of Oliver's (1991) framework allows us to relax the assumption that design choices are driven by pure economic rationality and incorporate institutional theory as a joint influence on network design. Institutional theory is a potentially important explanator of design choice, especially in public sector settings (DiMaggio and Powell, 1983, Meyer and Rowan, 1977 and Scott, 1992). Second, we study horizontal collaborations. Despite the increasing prevalence of horizontal inter-organisational relationships, we know little about the antecedents of structural and control system choices appropriate for such organisational forms (Caglio and Ditillo, 2008). There are particular challenges in the design and control of horizontal collaborations. While vertical inter-organisational activity tends to combine complementary capabilities, resources or processes across organisations, horizontal exchange of activity between organisations frequently combines potentially competitive or substitutable capabilities, resources or processes. This can result in complex inter-organisational interdependencies, and tensions between constituent and collaborative goals, which are quite distinct from those observed in vertical contexts (Mouritsen and Thrane, 2006 and van der Meer-Kooistra and Scapens, 2008). Finally, Chua and Mahama (2007) illustrate the importance of considering complex configurations of networks of inter-organisational relationships. Caglio and Ditillo (2008) note that while some studies are positioned as explorations of networks they in fact focus on dyadic inter-organisational relationships. In this paper we examine three networks of collaborative activity, collecting data from multiple organisations within each network. Drawing on this interview and archival data we identify a range of factors that explain observed differences in the strategic responses of hospitals to mandated network formation. We consider variation in the response of hospital networks to reflect perceptions of the likelihood of efficiency and legitimacy gains, the influence of constituent stakeholders, and the level of consistency between institutional and organisational goals.4 These antecedents impact on both the aims and the requirements of co-ordination, the potential for resource misappropriations and difficulties in aligning constituent and network objectives. Oliver identifies a range of strategic responses associated with these antecedent conditions – acquiescence, compromise, avoidance, defiance and manipulation. We assess the strategic response of hospitals and networks within this framework by focusing on structural and control system choices. The rationale for public sector hospital network creation was the achievement of efficiency and effectiveness gains and improved access to services through reduction in duplication and rationalisation of service offerings (Metropolitan Hospitals Planning Board, 1995). We examine the strategic response of organisations to the State-imposed efficiency imperative by exploring network integration. We consider how both formal and informal structural and control choices promote and manage integration between organisations of the network. We investigate design choices that include: the delegation and partitioning of decision rights; the design and use of performance measurement systems; the use of integrating mechanisms; and the use of standard operating procedures. These design choices reflect different levels of integration of core clinical activity, differential commitment to the ideals underlying the institutional mandate, and different strategic responses to institutional pressures. By examining the allocation of decision rights as well as operating and reporting processes, we are able: (i) to distinguish levels of commitment to integration from full network-level core service (clinical) integration from organisational designs which, in practice, privilege individual hospital authority and reporting structures; and (ii) to distinguish network-level integration from a façade of integration adopted to satisfy the demands of the State as a stakeholder. This distinction between appearances and reality is theoretically important as the appearance, rather than the fact of conformity, is often presumed to be sufficient for the attainment of legitimacy (Oliver, 1991, Scott, 1983 and Zucker, 1983). Our results provide support for Oliver's framework. In our empirical analysis of three hospital networks we observe tension in network design relating to efficiency, legitimacy, the influence of constituent stakeholders and perceptions of consistency between institutional and network goals. In one hospital network perceived efficiency gains from network formation, consistent with State priorities, support the full integration of clinical service delivery. This network provides a ‘model’ acquiescent response to the institutional mandate to collaborate; delivering efficiency and effectiveness outcomes though network governance. The other two networks, with less common clinical service profiles across the network, indicate scepticism regarding the ability to deliver efficiency gains consistent with institutional requirements or to derive legitimacy gains from compliance. In these networks the antecedents relating to the influence of other stakeholders and goal congruence explain their response to the institutional mandate. Their response reflects some attributes of a façade of compliance with the mandate to collaborate, while maintaining an operating structure and control systems which are decoupled from network-focussed governance. Such responses are consistent with those of compromise and avoidance that are described by Oliver (1991). In the following sections we develop our theoretical model, describe the study method and present our findings.

This study contributes to the extant literature in a number of ways. This is the first study we are aware of that investigates how institutional imperatives impact network design choices and one of a small number of inter-organisational studies situated in the context of horizontal, rather than vertical, relations between organisations. Further, we examine mandated public sector networks. We know little of the factors likely to promote or impede the efficiency and effectiveness of such networks, despite the increasing imposition of service delivery collaboration in this sector. We adopt Oliver's (1991) predictive factors model to explore institutional influences on organisational responses to mandated network formation. Analysing the interplay of these factors is important in public sector settings, where institutional factors are demonstrated to have particularly salient effects on design choices (Abernethy and Chua, 1996, DiMaggio and Powell, 1983 and Gupta et al., 1994). This model allows us to interpret how a range of institutional factors impact the complexities of horizontal network design and related control problems. By examining a setting in which network formation is mandated but discretion remains regarding the form of collaboration, we are able to examine empirically the way in which the tensions evident in Oliver's (1991) framework are revealed in the choices made by constituent organisations. Through analysis of the model we demonstrate differences in the interpretation and enactment of mandated reforms for service provision collaboration. The findings presented provide a rich source of contextual information as to the empirical manifestation of the institutional factors under examination, and support the model's predictions of the interdependent influence of institutional factors on structural and control system attributes. Consistent with prior research we demonstrate the importance of perceived efficiency and legitimacy gains on the response of organisations to institutional pressures (Abernethy and Chua, 1996, Gupta et al., 1994 and Roberts and Greenwood, 1997). Our findings also demonstrate the potential for influential constituents and low consistency between organisational and institutional goals to impede the efficiency and legitimacy imperatives underpinning reform agendas. In these conditions we observe substantive efforts to exhibit structural and control attributes that are largely decoupled from actual operations in order to either reflect conformance with, or ‘pacify’, institutional requirements. Relatively few studies apply the Oliver (1991) framework in the management accounting literature. Modell (2001) and Abernethy and Chua (1996) partially examine the model in a within-firm context. For example, Modell (2001) partially examines the relation between Oliver's predictive factors and the design of performance measurement systems within a hospital. Our study extends support for the usefulness of the Oliver (1991) framework to the understanding of inter-organisational responses to institutional pressures and illustrates the complexity of determining the collective response of multiple organisations in this context. Further, this study also contributes to the growing empirical research in management accounting that examines control mechanisms employed to meet the complex requirements of inter-organisational relationships. We examine inter-organisational design and control issues in horizontal collaborations. Such collaborations are relatively under-explored in the literature (Caglio and Ditillo, 2008), particularly in circumstances where institutional factors influence the incentives for constituent organisations to collaborate. Thus, we provide evidence of design and control choices in settings where potential efficiency gains are likely to be lower than those driving market-based alliances and where any such gains must be balanced against the need to manage diverse stakeholder interests. This setting is inherently different to that expected in vertical supply chain relationships, where potential synergies from collaboration, and the disadvantages of not collaborating, are more evident. Also, our results are informed by the study of complex networks of multiple organisations. This is significant in a context where much of the extant literature consists of insights from just one party to a dyadic relationship. In considering a range of control problems in these lateral inter-organisational relationships – co-ordination, co-operation and appropriation concerns – we further our understanding of the interdependent nature of control requirements and the limitations of parsing elements of the control problem and studying them independently. In demonstrating the interplay of formal and informal controls for the management of networks we consolidate the importance of investigating packages of controls, rather than individual control mechanisms. It is notable that mechanisms not explicitly included in the theoretical model surfaced as key elements of horizontal network control systems. In particular, further investigation of network-based cultures in exerting control could provide important insights in future studies. Finally, this study has practical implications for the architects of public policy as well as those responsible for implementing policy directives. Given the growing trend for the creation of mandated networks in the public sector, it is important to understand the consequences of such reforms on management structures and control system design. Without implementation of effective management structures and associated control systems, the efficiencies and improvements to delivery on which these reforms are predicated, will not occur. Our findings demonstrate the extent to which organisation-level responses can significantly influence the achievement of reform objectives. To this end public policy-makers can consider the advantages and disadvantages of creating policy directives that vest more or less discretion at the organisational level. Our findings are potentially directly transferable to other settings that are also currently the focus of public-sector reforms – for example, the amalgamation of institutes of higher education. The use of a case study method in this research is a powerful and flexible means of investigating the complex and relatively under-explored phenomena we study. We recognise that we draw on a limited number of cases. Our choice was to analyse a smaller number of cases in depth, to investigate how and why networks adopted particular design responses to mandated public sector reforms. We take care to ensure the rigour of qualitative data collection and analysis to avoid some of the pitfalls commonly associated with the case study method. The findings presented here provide a useful base to inform future research. Future research efforts could explore research settings that permit a more complete test of Oliver's predictive institutional factors model, including less institutionalised settings in which more resistant forms of responses (such as defiance and manipulation) may be anticipated. Amalgamations in other public sector settings that capture variation in the institutional factors of control and context could provide further insights into a broader set of predictive factors and strategic responses in an inter-organisational context. Overall the study potentially provides a catalyst for further comparative research within the domain of mandated public sector amalgamations, horizontal collaborations, and the factors that facilitate and impede structural reform in the public sector.