Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy




Rowe, W. Glenn


This dissertation contributes new insights on the antecedents and consequences of hospitals’ responses to institutions. It consists in three essays that collectively explore why and how hospitals balance their technical requirement of providing high-quality and affordable healthcare with an evolving constellation of institutional demands. The collective findings provide a contemporary perspective on the reconditioning of decoupling as a multi-form process, and a nuanced conception of factors affecting the institutionalization and deinstitutionalization of practices within hospitals.

Extending research on institutional leadership, Essay 1 examines hospitals’ approaches to an external mandate for energy conservation and climate mitigation. Through a qualitative investigation, it demonstrates how hospitals infused energy conservation values into the core structures and processes of their organization. It presents a distributed process model of institutional leadership wherein members of the organizational base create and maintain value systems in support of energy conservation, while disrupting pre-existing patient care routines that undermine value-infusion.

Essay 2 leverages recent advances in configurational methods to investigate how hospitals responded to a dual-pronged reform seeking to simultaneously reduce healthcare costs and improve the quality of clinical services. It finds that hospitals differed in their political, cultural and technical responses to this institutional change, and that four meta-configurations of responses accounted for a significant proportion of change in clinical outcomes in hospitals. A typology is developed to explain how each configuration likely affected clinicians’ use of best clinical practices and pathways.

Essay 3 integrates social identity-based leadership theory with resource dependence theory to develop and test predictions about hospitals’ responsiveness to women’s health issues. Using latent growth curve modelling, it analyzes baseline reporting levels and change in medical failures affecting women patients during childbirth in each hospital, and the effects of various covariates on these growth parameters. Findings show that female CEO-led hospitals have greater levels of commitment to women’s health issues, but that the effect of gender is attenuated by female CEO’s perception of resource dependence.

Summary for Lay Audience

Hospitals strive to provide affordable and high-quality healthcare. Yet, they must also satisfy the broader expectations of stakeholders, such as the state and clinical professions, in order to maintain their legitimacy and increase their access to resources. In this dissertation, I examine why and how hospitals respond to these stakeholder expectations.

Essay 1 studies Ontario hospitals’ responses to the Green Energy Act (2009) and pays special attention to how energy managers and their allies influenced the evaluation, adoption and implementation of energy conservation projects. I find that energy managers and their allies played an important role in the process of defining their hospital’s energy conservation vision and establishing dedicated roles and committees responsible for executing this vision in a decentralized manner. Energy conservation leadership depended on the work of individuals distributed at lower levels of the organization, and their ability to build support from senior executives, board members and frontline workers.

Essay 2 studies Ontario hospitals’ responses to the Excellent Care for All Act (2010) and the Health System Funding Reform (2012), which culminated in simultaneous pressures for cost containment and quality improvement for patients with chronic diseases. I examine how hospitals’ varying commitments to cost containment and quality improvement affected clinical outcomes, and identify four types of commitment combinations that account for a significant proportion of changes in patient readmissions. I elaborate how the four types of commitment combinations influence clinicians’ utilization of clinical best-practices and pathways.

Essay 3 studies Ontario hospitals’ responses to the Canadian populace’s concern about adverse events occurring to women patients in labour and delivery. It centres on whether Ontario hospitals led by female CEOs, as opposed to male CEOs, responded differently to these concerns. My findings suggest that female CEO-led hospitals were more likely to encourage clinicians to share information on medical failures during childbirth and to reduce the occurrence of these medical failures over time. However, when female CEOs perceived their hospital to be highly dependent on external stakeholders for their access to resources, their hospital tended to be less committed to these issues.