Making Service Improvement Happen

Abstract

This article illustrates the importance of social context in generating positive service improvement outcomes. Empirically, the qualitative research is based on a multilevel approach to theorizing from context. It considers the dimensions of the social and task contexts constraining and enabling service improvement in three Irish hospitals. Cross-sector case comparison (public, voluntary/nonprofit, and private sector) is used to consider the influence of task context, while attention to in-organization arrangements is used to consider the social context. The authors identify the influence of the task context on service improvement capacity and the influence of the social context on service improvement climate. Crucially, by taking account of service improvement outcomes, the authors identify both (a) the relative importance of the social context and (b) the impact of contextual configurations, through which the social context can either countervail or enhance task context effects. The findings suggest that organizations should focus on developing their social contexts to augment service improvement.

Keywords

climate context social hospital service improvement

Well-conducted qualitative research has great potential to illuminate context effects.

—Johns (2006, p. 402)

This research is based on the premise that “context counts” (Bamberger, 2008) and should be integrated into research (Johns, 2006; Pettigrew, Woodman, & Cameron, 2001). Studies in which the examination of context is a “declared and substantive research objective” are rare (Bacharach & Bamberger, 2007, p. 849). However, the research reported in this article explicitly considers the contextual factors constraining and enabling service improvement in Irish hospitals and presents an example of theory development premised on the direct observation and analysis of contextual effects (Rousseau & Fried, 2001). The article builds on previous research on the concept of the climate or “receptivity” (Ashburner, Ferlie, & Fitzgerald, 1996; Pettigrew, Ferlie, & McKee, 1992) for service improvement, affected by the social context, to take account of the underlying “capacity” for service improvement affected by the task context. We conclude that service improvement outcomes are more significantly influenced by the social (service improvement climate) rather than task (service improvement capacity) context of the cases considered, with climate working to either countervail or enhance capacity.

The article has five sections. First, the research goal is outlined. Next, the theoretical framework is provided. This is followed by discussion of the research design and presentation of the empirical data. Finally, our theory building and associated implications are explored.

The Research Goal

Public service reform and service improvement are significant concerns internationally. In the pursuit of improved public organization “performance,” policies have addressed both public service “structures” (Boyne, 2003)—described as the way in which services are organized—and the “agency” of the staff working within these structures—described as skills and attributes (Martin, Currie, & Finn, 2008). Structure and agency, respectively, relate to dimensions of the task and social contexts. However, there is little consensus on whether amendments to the task or social context have more impact in facilitating change.

In spite of significant increases in investment and expenditure (National Health Strategy Consultative Forum, 2001), and in line with international experience, Ireland has experienced sustained problems in attaining service improvement in health care. This has been attributed to the complexity of the health care context (National Health Strategy Consultative Forum, 2001). As a result, this research aimed to identify the contextual factors constraining and enabling service improvement change.

Theoretical Framework

In this section, we discuss the concepts of capacity and climate for service improvement. Following this, the literatures on context, change management, and service improvement and the specificities of health care as a research context are considered.

Capacity and Climate for Service Improvement

In spite of increasing recognition of the need to build change capacity, there is no clear definition of the construct (Judge, Bowler, & Douglas, 2006). In this research, capacity for change is defined as an organizational level construct that refers to the latent ability of the organization to successfully undertake service improvement change activities. As such, it is a measure of potential, focused on implementation and open to influence by organizational and environmental contextual factors (McDermott & Keating, 2010). Capacity for change differs from the cognitively focused construct of change readiness, which is focused at the individual level (Holt, Armenakis, Field, & Harris, 2007) and refers to the “organizational members’ beliefs, attitudes and intentions regarding the extent to which changes are needed and the organization’s capacity to successfully make those changes” (Armenakis, Harris, & Mossholder, 1993, p. 681). It also differs significantly from the concept of absorptive capacity, which refers to the recognition, assimilation, and application of external knowledge, for commercial reasons (Cohen & Levinthal, 1990; Jansen, Van den Bosch, & Volberda, 2005). Capacity for change across the cases is shown to be affected by environmental and organizational factors, specifically the interaction between governance, accounting system, and service planning system, through the underlying mechanism of autonomy.

The definition of organizational climate is contested (Patterson et al., 2005) with Dawson, Gonzalez-Roma, Davis, and West (2008) identifying consideration of climate as a global construct across organizations, and others considering subclimates for specific concerns, such as innovation (e.g., Anderson & West, 1998). We follow the latter approach and, like Schneider, White, and Paul (1998), consider the climate for service improvement as the level of support for service improvement in the organization. In essence, and similarly to receptivity for change (Pettigrew et al., 1992), the climate for service improvement refers to the extent to which there is a willingness to receive change in an organization and, therefore, exercise the available capacity for service improvement. In the organizations studied, climate is affected by dimensions of the social context, specifically the levels of strategic distraction in the organization, the extent of senior management support for service improvement, and the social structures in place.

The Role of Context in Organizational Research

The manner in which context has been considered in organizational research has been subject to increasing attention and critique (e.g., Bamberger, 2008; Dopson & Fitzgerald, 2005; Pettigrew et al., 2001; Rousseau & Fried, 2001). Context refers to the “situational opportunities and constraints that affect the occurrence and meaning of organizational behavior as well as functional relationships between variables.” (Johns, 2006, p. 386; also cited in Bamberger, 2008). Context is therefore multilevel, with environmental, organizational, and individual levels intertwined (Cappelli & Sherer, 1991). Hence, contextual variables can have cross-level effects (Johns, 2006).

A further differentiation between omnibus and discrete dimensions of context is provided by Johns (2006). Omnibus refers to broad consideration of context as a whole. In contrast, discrete context refers to particular contextual components that shape behavior or moderate relationships between variables. Johns (2006) notes that “the effects of omnibus context are mediated by discrete contextual variables or their interactions” (p. 391). Within discrete context, following Hattrup and Jackson (1996), Johns (2006) identifies task, social, and physical components. His examples of task context include uncertainty, autonomy, accountability, and resources. Examples of social context include social structure, density, and influence. Examples of physical context include the built environment and temperature, and so on. It is the particular dimensions of discrete context that interact to influence service improvement that are of interest in this article (rather than the service improvement processes themselves, per se). Several commentators have observed (e.g., Dopson & Fitzgerald, 2005; Johns, 2006) that contextual features are often studied in a piecemeal fashion, without attention to their configurational or cumulative impact. In moving to adequately address the multilevel and configurational nature of context in organizational research, contextualization (Rousseau & Fried, 2001) and context theorizing (Bamberger, 2008) have been advocated.

Change Management and Service Improvement

Failure rates in change programs remain high (Balogun & Hope Hailey, 2004; By, 2005) with problems reported in both transformational, strategic change (e.g., Pettigrew et al., 1992) and incremental operational change (e.g., Ferlie, Fitzgerald, Wood, & Hawkins, 2005). Poor success rates may reflect the lack of a valid framework for the implementation of change (By, 2005) or, as will become evident, a poor climate for change. In moving forward, the need to take account of both internal and external contextual arrangements has been noted by Greenwood and Hinings (1996). They suggest that internal contextual explanations may provide the most insight. Our focus in this research is on service improvement, a form of first-order change (Bartunek, 1987), in the health care sector.

Health Care as a Research Context

Health care organizations are complex multiprofessional milieus, which have been described as “pluralistic” (Bate, 2000) “negotiated orders” (Strauss, Schatzman, Bucher, & Sabshin, 1963), reflecting ongoing concern regarding whether and how key role groups can work effectively together in service provision and in contexts of change (Denis, Lamothe, & Langley, 2001). Effective working entails the management of socially constructed membership and task boundaries (Montgomery & Oliver, 2007) particularly as social and cognitive boundaries between professions can hinder the spread of innovation (Ferlie et al., 2005). As a result, collective change roles and leadership (Denis et al., 2001) increase the likelihood of successful change.

Method

Research Brief

As service improvement is enacted within organizational and environmental contexts, the research objective was to identify the contextual factors constraining and enabling service improvement. A cross-sector (public, voluntary, and private) comparative case study approach, together with consideration of in-organizational arrangements and service improvement processes aimed to illuminate the impact of contextual differences.

The Qualitative Approach

A qualitative methodology was appropriate (Yin, 2003) because of the descriptive and exploratory nature of the research, designed to facilitate explanation and theory generation (Eisenhardt & Greaebner, 2007). In addition, qualitative methods are more sensitive to context than quantitative methodologies (Denzin & Lincoln, 2005).

The Processual Approach and Data Collection

Within the qualitative framework, a processual approach was adopted. Three processual case studies were undertaken in cardiology. In the wake of the Irish National Cardiovascular Health Strategy, this was a high service improvement context in which approximately 60% of the strategy recommendations made were implemented (Fitzgerald, 2005). This facilitated consideration of successful and unsuccessful service improvement attempts.

Following Dawson (2003), the cases used retrospective analysis of service improvement processes, combined with real-time study of ongoing effects. We followed Pettigrew (1997) in undertaking comparative case studies, rather than longitudinal in-depth single case studies. As a result, in presenting our data we trade rich description of individual case processes for cross-case comparative insight into the contextual factors influencing these processes. A focus on identifying the underlying mechanisms mediating between context, processes, and outcomes is a feature of the processual approach.

Case selection was undertaken on the basis of sector, to facilitate representativeness. In Ireland, hospital sector is correlated with organizational complexity: Most voluntary hospitals are large, urban, teaching hospitals, most public hospitals are smaller rural hospitals, and most private hospitals are small scale—circa 120 beds. In each case study site, three forms of qualitative data were collected: in-depth interviews, document analysis, and informal direct observation (Yin, 2003). Exploring service improvement processes with a cross-sectional cadre of organizational respondents, including the senior management team, middle and clinical managers, and clinical representatives, provided multilevel insight into actors’ perceptions of why processes unfolded as they did, and the contextual factors that shaped them. A total of 51 interviews were undertaken across the three sites. Interviews were semistructured, recorded, and typically lasted between 40 minutes and 1 hour. The interview questions were divided into four sections, focusing on the hospitals’ history and context, the role and relationships of the respondents, and their involvement in two specific change initiatives, which were discussed in depth. This approach allowed questions to be directed at concrete situations, facilitating the report of personal observations and experiences (Alvesson, 2003).

Data Analysis

The first stage of analysis was undertaken on a case-by-case basis. All the interviews were transcribed and thematically analyzed with the use of NVivo, a qualitative data analysis program that assisted data management and analysis through the coding and retrieving of data in iterative cycles (Weitzman & Miles, 1995). First, the data were coded in NVivo using an a priori coding scheme, derived from the interview schedule. Additional codes were added as themes emerged in the analysis (e.g., the role of service-planning and accounting systems; capacity and climate for service improvement). The codes and coded items that were fed into the development of the “capacity” and “climate” constructs discussed in this article are presented in Table 1. The findings from each code were written up according to a specified case study template, so that each case was similar in structure. In this stage, narratives of the changes undertaken within each case were constructed (what Pettigrew, 1997, describes as analytical chronology of change). Following Langley (1999), the application of a temporal bracketing strategy to the narratives facilitated exploration of the contextual factors that constrained and enabled service improvement initiation, processes, and outcomes in each case. This strategy was adopted as, within the processual approach, multilevel theory construction takes place when attention is given to how contextual variables in the vertical analysis (context) link to those in the horizontal analysis (process; Pettigrew, 1985). In the second stage of analysis, an interpretive theoretical case analysis was undertaken, where emerging conceptual and theoretical ideas from each case were linked to prior research. To achieve this we compared the findings of each case with major themes from our literature review and prior research. Finally, a cross-case comparison, exploring within-case similarities and between-case differences was undertaken. This allowed us to identify generalizable themes across the cases. Adopting this strategy allowed us to follow Eisenhardt (1989) in allowing the unique patterns of each case to be considered, before cross-case comparison was attempted.

Table 1.

Examples of Codes and Coded Items Used in Analysis for Capacity (Governance, Accounting System, and Service-Planning System) and Climate (Social Structures, Senior Management Support, and Strategic Distractions)

Capacity: Governance
Code: Context/ environment and political context	I think with the recent changes with the HSE I have felt—and my colleagues have across the network—have a sense of being more disempowered than we have been. (General Manager, public hospital)
Description: The nature of the environmental or political context for change.	[We need] more autonomy for the individual hospitals. (Human Resource Manager, public hospital)
Capacity: Governance
Code: Context/Sector/ voluntary–public–private	There’s far too much centralized now . . . I think guidelines should be set [ . . . ] and then [the hospital] given autonomy. (Consultant, public hospital)
Description: How sector affects service improvement activities	I think I have much more autonomy [in private sector]. I can bring about change much more effectively in the sense that it is not bureaucratic. (Director of Nursing, private hospital)
Capacity: Accounting and Service-Planning Systems
Code: Context/accounting–service planning (code added as emergent theme)	[if] we agree that it is a good thing and we just go for it . . . (Quality Manager, private hospital)
Description: How accounting and service-planning processes affect service improvement activities	The service plans were done, but literally nothing happened as a result. (Human Resource Manager, public hospital)
Climate: Social structures
Code: Relationships/key relationships	They [dept heads] have a lot of autonomy and a lot of authority; they’re not coming back to check things with me. They might bounce things off me, but they’re not afraid to make decisions. (Director of Nursing, private hospital)
Description: Key relationships for service improvement activities	It can get increasingly frustrating if you feel you don’t have that support, or if you don’t have guidance or if you don’t have autonomy which is a big thing when it comes to decision-making. (Resuscitation Training Officer, voluntary hospital)
Climate: Senior management support
Code: Relationships/ managerial–clinical relationships	Many of the managers that have been here . . . I have found very supportive. Personally very supportive. And at a time, mind you, when funds were hard to get. (Consultant, public hospital)
Description: How managerial–clinical relationships affect service improvement activities	I have to say we’ve been very fortunate. The path ways of communications are very, very good. (Resuscitation Training Officer, public hospital)
Climate: Strategic distractions
Code: Context/strategy	If private hospitals are developed on public hospital sites then places like [the private hospital] are finished. (CEO, private hospital)
Description: Major strategic issues and distractions	We’re currently planning a private hospital here for this site. (Director of Nursing, voluntary hospital)

Note. HSE = Health Service Executive.

Theory building emerged from this iterative process of moving between the case and cross-case data, emerging themes, and extant literature (Eisenhardt & Greaebner, 2007). The core concern was to ensure that the theory accurately reflected the data.

Empirical Findings: Service Improvement Outcomes Achieved Across the Cases

To place the findings in context, an overview of the structure and context of each case is presented in Table 2.

Table 2.

Overview of the Structure and Context of the Three Cases

	Voluntary	Public	Private
Beds	500	200	110
Staff numbers	1,900	450	550
Funding (million Euros)	175	30	60
Governance structure and associated autonomy	Board mediates between organization and regional public sector body which allocates funds. As a result the hospital has moderate autonomy	Governed through regional public sector body which allocates fund. Little autonomy	Independent board. High autonomy, once performance maintained
Service-planning and accounting systems and associated autonomy	Determined at system level. Long-term planning constrained by yearly planning horizon and centralization	Determined at system level. Long-term planning constrained by yearly planning horizon and centralization	Flexible and responsive service-planning and accounting systems
Strategic distractions	High	High	Moderate, but increased focus on service improvement
Senior management support for service improvement	Low, because of strategic distraction	High, in spite of strategic distraction	High, once initiatives met clearly defined criteria
Social structures	High centralization, with consultant as gatekeeper. Low professional autonomy	Low centralization, with consultant as figurehead. Moderate professional autonomy	Low centralization. Consultant bypassed. High professional autonomy

Our focus on the contextual constraints and enablers of service improvement requires consideration of service improvement outcomes achieved. Following Buetow and Roland (1999), we define service improvement as any incremental development of the organizational, managerial, and clinical aspects of care. This broad conception reflects increasing recognition that quality is a systems property (Berwick, 2003) and that addressing concerns such as clinical safety requires attention to organizational issues such as the design of jobs, equipment, support systems, and organizations (Berwick, 2004). Across the three cases, organizational (infrastructure, space, and equipment), managerial (nature and form of service delivery, staff), and clinical service improvements (service expansion and development) were evident. We present the nature and outcomes of the service improvement initiatives undertaken in each case in Table 3. The clinical, managerial, and organizational improvements achieved in each case are discussed in the following subsections and then considered in the broader context of the scale and resources available in each organization.

Table 3.

Nature and Outcomes of Service Improvement Across the Cases

Nature of Improvement	Voluntary	Public	Private
Organizational: Infrastructure	Addition of cardiac catheterization laboratory	Acquisition and redevelopment of cardiac rehabilitation rooms and gym	Addition of cardiac catheterization laboratory
	Additional echocardiography rooms
Organizational: Space and equipment	Additional echocardiography equipment	Acquisition of echocardiography equipment and room	New department with additional space acquired for cardiac technicians
	Expansion/restructuring of resuscitation department	Acquisition of resuscitation training equipment and room
	New equipment obtained for cardiac care unit (CCU)	Acquisition of cardiac rehabilitation equipment
Managerial: Nature and form of service delivery	Change in use of three acute cardiology beds from 24 hour to day-case beds, to facilitate referrals	Clinical guidelines introduced across all services	System for management of free lab sessions introduced
	Cardiac arrest number standardized to be in line with other hospitals in the region	Two resuscitation training officers provide training to Advanced Cardiac Life Support Level. Previously only basic life support training was available on-site	Preprinted medication cards developed for use in catheterization laboratory
Managerial: Staffing	Threefold increase in number of cardiologists	An audit nurse, cardiac rehabilitation coordinator, cardiac psychologist, and two cardiac echocardiologists were appointed	Marginal increase in staffing levels, to support additional service
	Twofold increase in nursing staffing levels. For example, nurses attached to the CCU and cardiology wards increased from 17 to 40		Expansion of radiographer’s role
			Extended working day and weekend work introduced for two services
Clinical: Service expansion and development	Increase in service-provision in one area of care	Development of cardiac rehabilitation service. Previously ad hoc. Now two staff in place and phases one to four of cardiac rehabilitation (full range) provided to approximately 180 patients per annum. A pharmacy-led group-based medicine education program was also established	Development of one new specialty service. Achieved through equipment development and recruitment of specialist consultant
	Attempted development of cardiac rehabilitation. However, no increase in the level or range of services was achieved. The hospital is providing a smaller range of services to an equivalent number of patients as the public hospital	Development of echocardiography service. Transition from having untrained staff to a full service-provision department with four full-time staff and equipment
	Attempted introduction of medical-led cardiac arrest team review. This was not supported by the consultants in the organization and was not implemented	A resuscitation training department and community engagement program was established, with two staff. Training and equipment were provided to staff and the local community. Funds were raised to purchase community artificial external defibrillators
	Psychology services were extended to an additional service area	Introduction of clinical audit, accompanied by the appointment of an audit nurse

Service Improvement in the Voluntary Hospital

Notably, this was the only case where there was outright failure in clinical service improvement initiatives. Specifically, the introduction of a medically led cardiac review did not receive consultant support and therefore failed. In addition, staff attempted to develop cardiac rehabilitation services but no increase in the range or level of services was achieved. However, two incremental service developments were achieved. The most significant clinical service development was an increase in service-provision in one specific area of care. Psychological services were also extended to one additional care area. These marginal service improvements were disappointing in light of a threefold increase in cardiologists and a greater than twofold increase in nursing staff.

Two minor amendments to the nature and form of service delivery were achieved. The hospital changed three cardiology beds from acute to day-case usage, to facilitate referrals. They also standardized their emergency telephone number in line with others in the region. In infrastructural terms, additional rooms and equipment were acquired for two subservices. The most difficult initiative undertaken was the provision of a new cardiac catheterization laboratory. This called on the resource, technical, and social resources of the organization. Progress was inhibited by the failure to engage the professional groups involved. Similar problems led to difficulties in the achievement of increased staffing, the introduction of the medical-led cardiac arrest review, and the attempted expansion of service capacity in cardiac rehabilitation. Overall, the level of service improvement achieved in the voluntary hospital was disappointing, particularly as it was a resource-rich organization (as detailed in Table 4). It was the only organization to report outright failure in service improvement attempts. We classify the absolute level of service improvement achieved as low.

Table 4.

Levels of and Capacity for Service Improvement Across the Cases

	Voluntary	Public	Private
Level of service improvement	Low (one service expansion, remainder of progress limited to staffing and equipment expansion)	Moderate to high (a significant number of relatively small-scale but significant developments)	Moderate (one new service, potentially contentious staffing-related innovations, two significant infrastructural developments)
Relative level of service improvement	Poor (only case with outright service improvement failures, large scale, with significant budget)	High (small scale of organization, resource constrained)	Moderate (small scale of organization, resource rich)

Service Improvement in the Public Hospital

Although the public hospital was a smaller organization than the voluntary hospital, it achieved significant progress. It established three new services and gradually escalated service provision in each. It also introduced clinical audit. The establishment of each service required the acquisition of resources, the establishment of previously nonexistent technical expertise, and drawing on the social resources of multiple professions. Service establishment was highly successful. In fact, the hospital was providing a larger range of cardiac rehabilitation services to an equivalent number of patients as the 500-bedded voluntary hospital. With regard to managerial and organizational initiatives, five staff were appointed and two others were moved to support the echocardiography service. Ongoing refinements to clinical guidelines and training were put in place. Three rooms, a gym, and equipment for three services were obtained. This was achieved with one consultant in a 200-bedded organization that was almost omitted from consideration and funding under the National Cardiovascular Health Strategy. We classify the absolute level of service improvement achieved in this hospital as moderate to high, reflecting the number of relatively small-scale but significant developments.

Service Improvement in the Private Hospital

With regard to clinical service improvements, the private hospital introduced one new specialty service. It also made a variety of staffing-related amendments, to support service delivery. Specifically, it marginally increased staff levels to support the new service and changed the structure of both the job role and working week for nonconsultant staff in one department. Two additional amendments were made to service delivery, one of which was unsuccessful at the pilot stage. In space and infrastructural terms, it provided a new working area and equipment to one service, and developed a new cardiac catheterization laboratory. With the exception of the latter, the level of service improvement achieved was modest, based on minor adjustments. However, some of the initiatives undertaken were potentially contentious, such as amending job roles. Although resource constraints were not evident, the technical and social capacity of the organization was drawn on and worked well. Based on these outcomes, we classify the absolute service improvement achieved as moderate.

Comparing Service Improvement Across the Three Cases

The cardiac catheterization laboratories built in both the voluntary and private hospitals were the most significant infrastructural developments. Across the cases, the most notable service developments were in the public hospital, with three new services established. Although one service was extended in the voluntary hospital, there was negligible improvement across its other services. Next, we consider relative levels of service improvement, taking the scale and funding/resource constraints of each organization into account (as detailed in Table 2).

In comparative terms, the performance of the voluntary hospital, which was the largest organization, was disappointing. The public hospital achieved a higher level of service development and expansion, although it had only 40% of the bed capacity and less than 20% of the budget. However, the public hospitals’ funding constraints were evident in its limited infrastructural development. The small-scale and well-resourced private hospital achieved a significant capital development as well as some service development and reconfiguration. Based on this overview, we classify the relative level of change outcomes achieved in the voluntary hospital as low (low absolute service improvement in spite of large scale), those in the public hospital as high (moderate absolute service improvement, in spite of small scale and resource constraints) and those in the private hospital as moderate (moderate absolute service improvement in small but resource-rich organization). Having detailed the absolute and relative service improvement outcomes attained (summarized in Tables 3 and 4), the next sections consider the capacity and climate for service improvement in each organization, which are influenced by the task and social contexts, respectively.

Case Overviews of Capacity for Service Improvement

This section presents a case-by-case description and analysis of service improvement capacity. This was affected by the interaction between dimensions of the task context, specifically the governance, accounting system, and service-planning system in place in each organization.

Capacity in the Voluntary Hospital

Overall capacity

The voluntary hospital had moderate capacity for service improvement. This was underpinned by an independent board and its associated autonomy. However, the organization did face constraints imposed by the accounting and service-planning systems in place.

Governance

The voluntary hospital was independently owned by a religious order; governed by a board within parameters laid down by the Health Service Executive (HSE)¹ and, a member of a regional HSE hospital network for administration purposes (which is the case for all public and voluntary hospitals). The deputy CEO described the hospital as self-governing, self-managing and retaining “a fair degree of autonomy,” because of its independent ownership and governance. Several respondents emphasized the greater level of autonomy in place, in comparison with public hospitals. Implications included greater discretion regarding organization processes and decision making, greater reflexivity regarding the desirability of changes in the broader context, and more flexibility to facilitate entrepreneurial and other changes, even if not financially. However, the organization faced encroachment of its autonomy, associated with significant financing provided by the HSE and the restructuring of the health service. Nonetheless, the Deputy CEO emphasized that the organization was strategically attempting to offset this:

There seems to be a wish to bring the voluntaries into line under the National Hospitals Office pillar . . . but I think one of the huge benefits to the system of voluntarism is the autonomy that comes from within voluntarism that allows for fast change and manoeuverability and adaptation. (Deputy CEO, voluntary hospital)

There’s more flexibility internally in terms of how business is being done . . . things might be happening out there in the wider system that we have an inclination . . . to take a critical look at and say “Would that be right for us?” (HR Director, voluntary hospital)

Accounting and service-planning systems

Although the organization had some managerial discretion, it was restricted by resource constraints as well as constraints in accounting and service-planning systems, which were determined at the system level. Key issues included the desire for a greater than yearly planning horizon and to be informed of the budgetary allocation before the beginning of the operating year. There was also a strong desire to have organizational input taken into account in service planning, so that funding would be provided in line with local priorities. Finally, there was a desire to include depreciation of plant and equipment as an allowable expense, to facilitate long-term equipment planning. The capacity of all organizations across the voluntary and public sectors was constrained by these issues:

Funding comes in one-off bundles but you’re not thinking strategically about the physical building and there’s a huge impact on how good the quality of the services are. (General Services Manager, voluntary hospital)

Capacity in the Public Hospital

Outside of here you are blocked and you are questioned and at the end of it then you are saying “God, am I not the person best to know what is what, and what is needed?” (General Manager, public hospital)

Overall capacity

The public hospital had poor capacity for service improvement. It encountered constraints in flexibility, discretion, and autonomy, because of the governance structure, accounting, and service-planning systems in place. In addition, as a small organization in a network, it suffered in terms of both primacy and resource allocation.

Governance

The public hospital had a significant lack of senior management autonomy, because of the governance structure in place. The hospital was governed through the regional hospital network. The “network manager” for all the hospitals in the region acted as a link between the individual hospitals and the HSE. This was a relatively new structure and the general manager articulated a sense of disempowerment associated with it. Of particular concern was the centralization of decision-making power at the regional level, undermining organizational autonomy. Decisions were made by the general manager, but could be overridden at the regional level. In contrast, the presence of the independent board in the voluntary hospital meant that decisions made within the organization tended to be upheld:

I feel I am becoming more of a puppet. And it is demoralizing in some ways, when you really put your energy behind something. (General Manager, public hospital)

Accounting and service-planning systems

The governance structure emphasized oversight and stewardship, which were also evident in the accounting and service-planning systems. These further constrained the discretion of the organization. The accounting system hindered service improvement by undermining the benefit of identifying efficiencies. For example, if the organization reduced actual relative to budgeted spend, it could not divert funds to support service improvement or other initiatives:

Spent properly seems to be more important than spent efficiently. That is because of the stewardship role and I tick the box to say yeah the million is gone over there. I might have been able to buy it for a half a million but it is gone over there and all of those boxes are ticked. (Director of Finance, public hospital)

The service-planning system constrained the public hospital via two dynamics. First, as a small organization in a network of hospitals, it suffered in regard to resource allocation. The network structure also meant that the general manager could not liaise directly with the funder. This had historically allowed the organization to “make the case” for extra resources. Second, the criteria on which regional funding was allocated were not published. Hence, the hospital had no grounds on which to appeal resource-allocation decisions relating to service delivery or improvement:

What I would really like is that there’s more fair play and equity and transparency in terms of how the resources is divvied out. (General Manager, public hospital)

Capacity in the Private Hospital

It’s kind of easy to get things done here. Basically it’s very yes and no; we know the protocol for things if you want something. You know business cases have to be done up, and you have to make arguments and there has to be a return on investment. So you know going to the board, if you are putting a paper to the board, whether it will get passed or not. (Cardiac Services Manager, private hospital)

Overall capacity

The capacity for change in the private hospital was high, with significant autonomy, clear criteria for evaluating service improvement initiatives, and processes which supported the speedy implementation of those approved. However, service improvement initiatives were required to meet defined business and quality criteria.

Governance

The independent board, which had strong representation from financial investors, set 10 specific financial and quality-related targets annually. The CEO was afforded significant autonomy in how the targets were attained. However, continued autonomy was based on meeting these targets, which were cascaded down the organization:

Key priorities here are to deliver on the objectives of the board . . . there’s about 10 objectives, some of them financial, some of them quality . . . I have huge autonomy. As long as I deliver . . . (CEO, private hospital)

Accounting and service-planning systems

The accounting and service-planning systems facilitated service improvement. These were evaluated on the basis of business cases, with explicit business and quality criteria that were communicated to all staff. Initiatives meeting these criteria were speedily implemented and not constrained by a specific planning cycle:

Decisions are made very quickly. It’s very clear; you look at clinical need and business cases and it’s not as complicated. There’s not as many stakeholders and there’s not as much jumping through hoops. (Director of Nursing, private hospital)

I can bring about change much more effectively in the sense that it is not bureaucratic. (Quality Manager, private hospital)

Cross-Case Overview of Capacity for Service Improvement Change

The capacity for change across the cases has been identified as moderate in the voluntary hospital, low in the public hospital, and high in the private hospital. A summary of the by-case findings is provided in Table 2, with quotes in support of the findings across the cases summarized in Table 5.

Table 5.

Capacity for Service Improvement and Influencing Factors

	Voluntary	Public	Private
Capacity for service improvement	Some of the reason that things don’t get done is that there’s almost a structural imperative to slow things down; to have the optical illusion that we’re actually doing a lot of things. But because there’s resource rationalization which isn’t acknowledged . . . it takes too much. (Deputy CEO)	Outside of here you are blocked and you are questioned and at the end of it then you are saying “God, am I not the person best to know what is what, and what is needed?” (General Manager)	We know the protocol for things if you want something. You know business cases have to be done up, and you have to make arguments and there has to be a return on investment. So you know going to the board, if you are putting a paper to the board, whether it will get passed or not. (Cardiac Services Manager)
Governance systems (autonomy)	I’ve never seen it in writing, but people in the Department of Health would have said, “Well, you are a voluntary hospital, get on and do it if you want to.” (Mission Effectiveness Co-coordinator)	I think with the recent changes with the HSE I think that I have felt—and my colleagues have across the network—have a sense of being more disempowered than we have been. I just feel that who makes decisions should be taken up the line. (General Manager)	I have huge autonomy. As long as I deliver the financial returns and the patients don’t complain, I’m left to my own devices. Which is the attraction of working here. (CEO)
Accounting systems	It’s a serious flaw in the system that you cannot provide for the replacements to your equipment and have it as an allowable expense in your account. Because then you could plan your replacements and do it on a logical basis. (Director of Finance)	We don’t have an equipment depreciation budget. So when something is on its last legs, every time it happens, it’s a crisis. There’s no planning. (Medical Director)	The great thing about working in the independent sector is decisions are made very quickly. It’s very clear; you look at clinical need and business cases and it’s not as complicated. There’s not as many stakeholders. (Director of Nursing)
Service-planning systems	I have to say . . . you go through too many people [outside the organization] before a decision is made. (Director of Nursing)	I think em what I would really like is that there’s more fair play and equity and transparency in terms of how the resources is divvied out. (General Manager)	In comparison to the public hospitals etc. there’s very little bureaucracy, and I think, very little hierarchy. To me you get things through quicker. (Head of Finance)

Note. HSE = Health Service Executive.

The constraints encountered in the public and voluntary hospitals pertained to the nature of the governance, accounting, and service-planning system, aspects of the task context which acted in configuration to affect the capacity for service improvement. Underpinning these findings was the “generative mechanism” of autonomy (Johnson & Duberley, 2000). Specifically, governance systems affected the level of autonomy to facilitate change. As per Table 2, the voluntary hospital had some autonomy, the public hospital had little autonomy, and the private hospital had high autonomy. Table 2 also indicates that, for the voluntary and public hospitals, the service-planning and accounting systems further constrained discretion regarding resource allocation and distribution. In contrast, these systems were flexible and responsive in the private hospital. Next, we consider the climate for service improvement, affected by aspects of the social context.

Case Overviews of the Climate for Service Improvement

The climate for service improvement is influenced by the social context, specifically the levels of strategic distraction, senior management support, and the social structures in each organization.

Climate in the Voluntary Hospital

Overall climate

The voluntary hospital had a poor climate for service improvement, because of high levels of strategic distraction, low senior management support, and centralized social structures.

Strategic distractions and senior management support

There was low motivation to engage in change at the organizational level, because of resource rationalization and associated high levels of strategic distraction, which removed senior management attention and support from day-to-day operations and service improvement. Strategic distractions included day-to-day resource constraints with increasing demand for services, the completion of a major capital development, plans to develop a new private hospital, and changes to the senior management team.

Social structures

The voluntary hospital had a highly centralized and consultant-centered social structure. The hospital was a member of a regional cardiovascular strategy implementation network. However, the centralized social structure undermined potential benefit, by failing to empower or support frontline staff in their service improvement endeavors. In contrast, in the public hospital the legitimacy of frontline staff participating in service improvement was supported by the network. This facilitated the development of relationship groupings, and peer mentoring within and across professions and organizations. In the public hospital, staff used this to identify ideas and initiatives which they could bring back to their own organization. This contrasts markedly with the scenario in the voluntary hospital, where nonmedical staff were not empowered to engage in service improvement, and did not, therefore, derive benefit from the network:

It’s really a patriarchy approach that’s wrapped up in health care where women just look after the shop and the boys go off hunting and come back every so often. (Deputy CEO, voluntary hospital)

Centralization meant that the consultants were viewed as “gatekeepers,” whose support was required to move things forward. This is reflected in a clinical nurse manager’s (CNM) assertion that “If I want to get something done I’ll go to one of the consultants.” In addition, staff had to proactively draw attention to issues as the consultants tended not to engage with them. This was evident during the installation of the new cardiac catheterization laboratory. Nonmedical staff emphasized the lack of communication and engagement during the process, which led to implementation difficulties. This was captured in the assertion that,

They don’t sit down with the people who are the stakeholders and talk with them about what the plan is and then listen to them about their difficulties or how they see a problem. That doesn’t really happen very well. (CNM2 Catheterization Laboratory, voluntary hospital)

I said “yes and I’m going to keep saying it because I know that I’m not being listened to and I know what’s going to happen.” (CNM2 Catheterization Laboratory, voluntary hospital)

In the voluntary hospital, strategic distractions undermined senior management support for service improvement. In combination with the consultant-centered social structure and the failure to communicate and engage with nonconsultant staff, this led to a poor climate for service improvement. Unnecessary difficulties were encountered and nonmedical-led service improvements were uphill battles that, as reported in the “Empirical Findings: Service Improvement Outcomes Achieved Across the Cases” section, sometimes resulted in failure.

Climate in the Public Hospital

We are very professional when we are working, and we get everything done; people are willing to do it because we are a cohesive group. (Assistant Director of Nursing, public hospital)

Overall climate

The public hospital had a supportive climate for service improvement in spite of significant strategic distractions. The supportive climate was attributable to senior management support and the devolution of service improvement responsibility within the organization’s social structures.

Strategic distractions and senior management support

In spite of significant strategic distractions, including consolidation against potential downgrading in status, encroachment on managerial autonomy, and a perceived poor position with regard to resource allocation, the senior management team retained a proactive focus on day-to-day operations and the management of change. Senior management team attention was facilitated by a cohesive culture:

Many of the managers that have been here . . . I would have found very supportive . . . And a time, mind you, when funds were hard to get. (Consultant Cardiologist, public hospital)

Everybody knows everybody else. (Assistant Director of Nursing, public hospital)

Social structures

The social structures in the public hospital encouraged partial devolution of responsibility for service improvement. The consultant liaised with staff to establish a vision for the department, the implementation of which was then partially devolved to staff. This encouraged entrepreneurial individuals to identify and implement resource-neutral and externally resourced changes:

I did most of the ground work. And then I’d go to [the consultant] to check it (Cardiac Rehabilitation Co-coordinator, public hospital)

We have a very good reporting structure . . . you can progress certain things for your own department through [the medical director] and then you can progress other things as a group. (Chief Pharmacist, public hospital)

In describing the service improvement processes in which they were involved, staff repeatedly emphasized the collaborative and collegiate nature of service improvement and the autonomy afforded to them by the consultant in developing their own subareas. Difficulties encountered predominantly related to infrastructure, resource and staffing deficits, and constraints in organizational autonomy. In particular, the cardiologist referred to “huge deficiencies in the infrastructure for the cardiac department.” The organization engaged in as much service improvement as was safe within the constraints posed:

We have in the past tended to take on new tasks without having enough staff. You know, you can do that to a certain degree, but you can’t do it to a point where it gets dangerous and where you are putting people under pressure. (Chief Pharmacist, public hospital)

The combination of senior management support and social structures, which encouraged involvement in service improvement led to the development of a supportive climate for service improvement.

Climate in the Private Hospital

Probably the advantage to working in the private sector is that you actually get work done. (Consultant Cardiologist, private hospital)

Overall climate

The private hospital provided a highly supportive climate for service improvement initiatives that met specific financial and quality criteria.

Strategic distractions and senior management support

Interestingly, in contrast to the other cases, the climate in the private hospital was augmented by external strategic developments, particularly increasing competition for patients and staff caused by tax breaks for private hospitals. In response, the hospital had initiated infrastructural development to consolidate its strategic position. The changes in the environment, the planned capital development of the hospital, and attracting consultants were occupying much senior management attention. However, the need to maintain profitability led to a continued focus on service improvements meeting specified criteria. Senior management support for initiatives meeting these criteria was structurally embedded in the organization, as detailed below.

Social structures

Responsibility for service improvement was devolved to department heads, with two supporting roles in place (a quality manager and cardiac services manager). Initiatives were proactively identified from a variety of sources, including frontline staff, the board, and senior management:

It could come from the ground up; it could be some consultant saying they’ve been to a conference and there’s a new . . . it could be from clinical people themselves . . . All suggestions are always received and looked at. (Head of Finance, private hospital)

Once ratified, support was afforded to the implementation of initiatives. This is evidenced in the fact that, unlike the voluntary hospital, a range of staff described the introduction of the catheterization laboratory in positive terms such as “quite good really” (Clinical Nurse Manager), “very controlled” (Cardiac Services Manager), and “smooth” (Consultant Cardiologist).

Cross-Case Comparison of Climate for Service Improvement

The climate in each case was influenced by strategic distraction, senior management support, and the social structures in place. These are summarized for each case in Table 2. Quotes evidencing the different climates across the cases are presented in Table 6. In the voluntary hospital, high strategic distraction undermined senior management attention on, and support for, service improvement. In contrast, the public hospital had high senior management support, in spite of high strategic distraction. Finally, in the private hospital moderate strategic distraction increased senior management support for service improvement meeting defined criteria. The voluntary hospital social structures were highly centralized around the consultant, with low autonomy for other professions. In contrast, the public hospital combined low centralization with moderate professional autonomy, with staff able to facilitate service improvement in line with a cocreated strategy. Finally, the private hospital had complete devolution. In each case the social structures in place were the most influential factor, underpinning the extent to which (a) there was local autonomy for service improvement and (b) whether this was shared across professions. The extent of strategic distraction and senior management support enhanced or detracted from the broader climate generated by social structures.

Table 6.

Climate for Service Improvement and Influencing Factors

	Voluntary	Public	Private
Climate for service improvement	I’d be aware that people are challenged maybe by a lot of the changes but no difficulties, like I suppose you might say to me well what evidence have I got, how many times was I in the Labor Court or in the Labor Relations? None. (Director of Nursing)	There were times when you’d try to implement change and found it difficult more so than it didn’t get done. It’d get done in the end. (Clinical Nurse Manager 2, coronary care unit)	If the thing made sense from a business point of view it got done very quickly whereas you could be at it for years in the public hospitals and get nowhere. (Consultant 2)
Strategic distraction	There’s a lot of things going on in the hospital, a lot of planning of, you know, infrastructure, new buildings, new hospitals, all of that sort of thing. (Director of Finance, voluntary hospital)	There are times when I am not comfortable with it myself, even though I know that I am making a decision. It is not what I would really want myself . . . but I have no choice but to. ’Cause I have other factors determine or dictate. (General Manager)	[Private Hospital] is moving . . . to a situation where there’s going to be over supply, where hospitals will be competing with one another for consultants and indeed clinical staff because of the huge shortage of them. (CEO)
	The actual limitations of what we do can be very straight forward; like we don’t have enough beds. (Director of Finance)
Senior management support	There’s learning to be derived from it. I think if one was doing it again I think one would certainly hear the voice more of the non-consultants who have the in-the-trench understanding of the minutiae of issues that do matter. (Deputy CEO)	They saw me as somebody “Here’s a guy who’s come to [Public Hospital], wants to develop the service, goes out every second night of the week raising funds for the hospital.” . . . That makes it much easier to go to management. To say “look guys, I’m working for the hospital, you work for me, help me out” And they do. (Consultant Cardiologist)	It could come from the ground up; it could be some consultant saying they’ve been to a conference and there’s a new . . . it could be from clinical people themselves . . . All suggestions are always received and looked at. (Head of Finance)
Role-structures in place	Consultant centered/consultant as gatekeeper	Partially devolved/consultant as figurehead	Devolved/consultant bypassed
	One of things that I did really learn when I came here was that people work within their own silos, very much so. (Director of Nursing)	We just said we’d do it. Told [the consultant] at a meeting and he said “ok, that’s brilliant.” (Cardiac Rehabilitation Co-coordinator)	Clinical managers “have a lot of autonomy. We’re let manage our own departments” (CNM2 Cardiac Ward)

Discussion and Conclusion

Contextual differences can be a major source of conflicting findings, and teasing out underlying patterns requires us to pay more attention to research settings. (Rousseau & Fried, 2001, p. 2)

In this article, we set out to examine how contextual factors influence service improvement, moving to address the deficit in research which explicitly explores context as a substantive research objective (Bacharach & Bamberger, 2007). In focusing on service improvement events (Rousseau & Fried, 2001) in cross-sector contexts, our data analysis led to the identification of configurations of contextual factors affecting service improvement outcomes in hospitals. Our contribution in this regard is twofold. First, we identified the combinations of discrete contextual factors affecting service improvement capacity and climate. Specifically, our cross-sector analysis draws attention to dimensions of the task context that influenced change capacity (i.e., the governance, accounting, and service-planning system). We also established that dimensions of the social context influence the internal climate for change (i.e., the extent of strategic distractions, senior management support, and the social structures in place). Both the social and task contexts were underpinned by the “generative mechanism” of autonomy. In the case of social context, autonomy is manifested in the form of the social structures in place and the associated extent of centralized decision making. For example, in the voluntary hospital, staff did not have autonomy to progress initiatives without the support of the consultant. In contrast, in the public hospital, staff had autonomy to undertake initiatives in line with the agreed department vision. Finally, autonomy was devolved to clinical managers in the private hospital. With regard to the task context, autonomy was influenced by the governance, accounting system, and service-planning system in place in each organization. For example, in the public hospital the general manager felt that the governance system constrained autonomy, as decisions had to be sanctioned by the region’s hospital network manager. In contrast, the existence of a board of governors in the voluntary hospital protected the organization from such dynamics. In the private hospital, the board afforded the CEO discretion in how to manage the organization, once performance targets were attained.

Second, our more salient theoretical contribution arises from the integration of service improvement capacity, climate, and outcomes across the cases, as per Table 7 and Figure 1. The findings illustrate countervailing contextual influences in action (Johns, 2006) with climate for service improvement, influenced by dimensions of the social context (strategic distractions, senior management support, and the social structures in place), acting in configuration to countervail or enhance capacity, influenced by dimensions of the task context (governance, service-planning system, and accounting system). This provides insight into the relative influence of the task and social dimensions of context across the cases—with the social context emerging as the key facilitator of service improvement. The capacity of social context to either countervail or enhance the task context is emphasized by the inclusion of plus and minus signs in Figure 1. For example, Table 7 illustrates that in the public hospital, the case with the least capacity for service improvement, senior management support, and the partially devolved social structures in place (dimensions of the social context) led to a supportive climate that countervailed the poor task context, leading to better service improvement outcomes than expected. Thus, our analysis moves beyond presenting a taxonomy or configuration of contextual factors, toward identifying social context as the significant driver and facilitator of service improvement, working to either countervail or enhance the task context.

Table 7.

Overview of Capacity and Climate

	Voluntary	Public	Private
Relative level of service improvement	Poor	High	Moderate
Capacity	Moderate	Poor	High
Climate	Poor	Highly supportive	Supportive for initiatives meeting defined criteria

Figure 1.

The role of social context in achieving service improvement

Implications for Theory and Research

The importance of in-organizational arrangements for organizational functioning has long been recognized. For example, Greenwood and Hinings (1996) note that intra-organizational dynamics explain differential levels of radical organizational change, in the face of apparently similar contextual pressures. Our research sheds light on why this is the case, in contexts of service improvement. Studies of change to date have tended to prioritize dimensions of the social context (e.g., Denis et al., 2001; Holt et al., 2007; Lewin, 1947) or consider the cumulative influence of context, without explicit attention to the relative influence of social and task dimensions. For example, in research on strategic change, attention has been afforded to the relationship between the structural context, top managers, and strategic activity (e.g., Johnson, 1987; Pettigrew et al., 1992). However, how structural context interacts “with other factors in shaping strategy is relatively underexplored” (Jarzabkowski, 2008, p. 621). The core contribution of this article is to suggest the primacy of social context in facilitating service improvement change, and to emphasize its capacity to countervail or enhance task context effects. This finding suggests a need for further research in three regards:

The research focused only on first-order change. Future research should consider the relative role of social and task contexts in second-order change.

The research findings require testing in additional research settings. The research was undertaken in health care, a professional service context with a history of hierarchical and, at times strained, interprofessional relationships and high professional autonomy. We speculate that our findings should hold across other professional service and cross-professional work contexts, where knowledge sharing and cross-professional collaboration make social context central to service delivery and improvement. However, future research should also explore the role of social context in high-certainty task contexts that combine high hierarchy with little job-related autonomy (e.g., manufacturing). This is important as proactive behaviors central to change—including problem solving, idea generation, and implementation—are more likely under conditions of autonomy (Parker, Williams, & Turner, 2006).

Finally, although we have established the primacy of social context, we note that task context remains influential. As a result, we advocate research approaches that take account of both. From a theoretical perspective, Giddens’s (1984) structuration theory is useful in this regard. This emphasizes that agency and structure jointly inform social action, and explicates their mutual influence. This approach has been successfully adopted in strategy research (e.g., Jarzabkowski, 2008) and could be a fruitful approach for future studies of change.

Interestingly, in conceptualizing the institutional realm, Giddens (1984) identified three forms of structure—signification, legitimation, and domination. Domination, emphasizing authority relationships and resource-allocation structures, features strongly in our analysis, cutting across social and task contexts. Hence, although structuration does not precisely mirror our conceptual framework of context, it suggests, in line with the findings of this article, that the historical focus of change research on social agency (e.g., as in force-field analysis and people-centered approaches to change such as Organization Development), should be broadened to take account of the task context. Consistent with Cappelli and Sherer (1991), we note that the environment provides the task context for the organization and the organization provides the social context for individuals, with the social context being most influential in our findings.

Implications for Policy Makers and Managers

The findings of this article have twofold implications for policy makers and managers, associated with the importance of (a) autonomy and (b) social context. First, the centrality of autonomy to the research findings—in governance at the organizational level and in social structures at the individual level—is unsurprising as “the degree of autonomy, or freedom of action, that an individual, team or organization has is one of the most omnipresent contextual factors.” (Johns, 2006, p. 394). However, the findings are at odds with previous findings regarding the benefits of centralization (Boyne, 2003) in the public sector and with pressures for accountability associated with hierarchical modes of governance. The centrality of autonomy to the research findings has implications for policy makers in the design and implementation of reform, suggesting that governance, service planning, and business processes should facilitate flexibility (e.g., the important differentiation between rules and guidelines). Similar issues will arise for managers, who may need to consider how reporting relationships or job design can empower role-holders and provide them with autonomy and flexibility.

The findings also pose interesting policy questions about the most appropriate locus of reform in the pursuit of public-service improvement. Policies for public-sector reform have previously addressed both public service structures (Boyne, 2003) and the agency of the staff working within these structures (Martin et al., 2008; i.e., the task and social contexts, respectively). For example, in health care, clinical directorate structures (Lega, 2008) and clinical management roles (Llewellyn, 2001) have been introduced as structure- and agency-oriented responses to the problem of bridging the medical–management divide. However, the relative significance of the social context, as demonstrated in this research, may signal a need for further reflection on, and evaluation of, structural reform. Indeed, given the agitating nature of structural change it may serve to further undermine the social context. Our findings suggest that policy makers should, in the first instance, consider how they might positively influence the social context of organizations to achieve service improvement. For example, the data suggest that job-based autonomy and support are more important than organizational autonomy in facilitating service improvement. Specifically, organizational autonomy and resource availability are less important than the social structures in place and social influence afforded to staff (particularly nonmedical staff) in securing service improvement. Hence, exploration of how autonomy and discretion can be facilitated might consider local social structures, management support, and flexibility in job design.

Generalizability and Limitations of the Research

This research has compared service improvement outcomes in different organizations, requiring consideration of relative service improvement, in this case taking account of scale and available resources. However, although this has posed challenges, the associated cross-sector nature of the research design has facilitated insight into the contextual factors at the organizational and environmental levels that affect change processes. Hence, it is both a weakness and strength of the research.

As a caveat, although resources might have been expected to feature more strongly, the climate for individual service improvements was augmented by the provision of resources. We also recognize that our findings are premised on service improvement, rather than strategic change. More generally, our findings require caution in interpretation and extrapolation because of the small scale of the research, undertaken in one sectoral and national context which may not be representative. Nonetheless, we are mindful of Yin’s (2003) notion of analytic generalization and his argument that although it is problematic to generalize from one case to another, case researchers can attempt to generalize to theory. As a result, we propose “moderatum generalization” (Payne & Williams, 2005), where we recognize the limited and hypothetical nature of our findings. This is in line with Bamberger (2008) and, following him, we draw attention to the generative value of the research and the potential for other researchers to further test and extend the theoretical refinements presented. We propose our finding of the importance of the social, rather than task, context in producing service improvement outcomes as a “testable proposition,” to be explored in line with the suggestions in the Implications for Theory and Research subsection. On this basis, propositions may include the following:

Proposition 1: High-autonomy task contexts will precipitate service improvement.

Proposition 2: High-autonomy social contexts will precipitate service improvement.

Proposition 3: Autonomy in the social context will have a greater effect on service improvement outcomes than autonomy in the task context.

Proposition 3a: A supportive social context may countervail a negative task context.

Proposition 3b: A negative social context may undermine a supportive task context.

Conclusions

In adopting a process-based methodology, this research has brought together multilevel contextual influences from the social and task contexts to explain practice issues. Our findings identify the task context as potentially precipitating (or constraining) service improvement. However, we have found this to be neither necessary nor sufficient for achieving service improvement. Rather we have identified the need for a receptive social context for service improvement to occur. In addition, we note the impact of configurations of context, whereby the social context can enhance or nullify task context effects.

Footnotes

Acknowledgements

The authors thank Louise Fitzgerald, Edel Conway, Denise Rousseau, Patrick Flood, David Coghlan, David Jacobson, Ewan Ferlie, and three anonymous reviewers for the 2009 Academy of Management Conference for helpful suggestions regarding the development of this paper. We also thank Richard Woodman and three anonymous JABS reviewers, whose insights and support led to significant improvements. Any errors or omissions remain our own.

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

The authors disclosed receipt of the following financial support for the research and/or authorship of this article:

The first author received support for this research from the Irish Research Council for the Humanities and Social Sciences through their post-graduate scholarship scheme.

Notes

References

Alvesson

(2003). Beyond neo-positivists, romantics and localists: A reflexive approach to interviews in organizational research. Academy of Management Review, 28, 13-33.

Anderson

West

M. A.

(1998). Measuring climate for work group innovation: Development and validation of the team climate inventory. Journal of Organizational Behavior, 19, 235-257.

Armenakis

A. A.

Harris

S. G.

Mossholder

K. W.

(1993). Creating readiness for organizational change. Human Relations, 46, 681-703.

Ashburner

Ferlie

Fitzgerald

(1996). Organizational transformation and top-down change: The case of the NHS. British Journal of Management, 7, 1-16.

Bacharach

S. B.

Bamberger

P. A.

(2007). 9/11 and the New York City fire fighters’ post hoc unit support and control climates: A context theory of the involvement in traumatic work-related events. Academy of Management Journal, 50, 849-868.

Balogun

Hope Hailey

(2004). Exploring strategic change (2nd ed.). London, England: Prentice Hall.

Bamberger

(2008). Beyond contextualization: Using context theories to narrow the micro-macro gap in management research. Academy of Management Journal, 51, 839-846.

Bartunek

(1987). First-order, second-order and third-order change and organization development interventions: A cognitive approach. Journal of Applied Behavioral Science, 23, 483-500.

Bate

(2000). Changing the culture of a hospital: From hierarchy to networked community. Public Administration, 78, 485-512.

10.

Berwick

D. M.

(2003). Improvement, trust and the healthcare workforce. Quality & Safety in Health Care, 12, 2-6.

11.

Berwick

D. M.

(2004). The improvement horse race: Bet on the UK. Quality & Safety in Health Care, 13, 407-409.

12.

Boyne

G. A.

(2003). Source of public service improvement: A critical review and research agenda. Journal of Public Administration Research and Theory, 13, 367-394.

13.

Buetow

S. A.

Roland

(1999). Clinical governance: Bridging the gap between managerial and clinical approaches to quality of care. Quality & Safety in Health Care, 8, 184-190.

14.

R. T.

(2005). Organisational change management: A critical review. Journal of Change Management, 5, 369-380.

15.

Cappelli

Sherer

P. D.

(1991). The missing role of context in OB: The need for a meso-level approach. In Cummings

L. L.

Staw

B. M.

(Eds.), Research in organizational behavior (Vol. 12, pp. 55-100). Greenwich, CT: JAI Press.

16.

Cohen

Levinthal

(1990). Absorptive capacity: A new perspective on learning and innovation. Administrative Science Quarterly, 35, 128-152.

17.

Dawson

(2003). Reshaping change: A processual perspective. London, England: Routledge.

18.

Dawson

J. F.

Gonzalez-Roma

Davis

West

M. A.

(2008). Organizational climate and climate strength in UK hospitals. European Journal of Work and Organizational Psychology, 17, 89-111.

19.

Denis

J. L.

Lamothe

Langley

(2001). The dynamics of collective leadership and strategic change in pluralistic organizations. Academy of Management Journal, 44, 809-837.

20.

Denzin

N. K.

Lincoln

Y. S.

(Eds.). (2005). The Sage handbook of qualitative research (3rd ed.). London, England: Sage.

21.

Dopson

Fitzgerald

(2005). The active role of context. In Dopson

Fitzgerald

(Eds.), Knowledge to action: Evidence-based healthcare in context (pp. 79-103). Oxford, England: Oxford University Press.

22.

Eisenhardt

K. M.

(1989). Building theories from case study research. Academy of Management Review, 14, 532-550.

23.

Eisenhardt

K. M.

Greaebner

M. E.

(2007). Theory building from cases: Opportunities and challenges. Academy of Management Journal, 50, 25-32.

24.

Ferlie

Fitzgerald

Wood

Hawkins

(2005). The non-spread of innovations: The mediating role of professionals. Academy of Management Journal, 48, 117-134.

25.

Fitzgerald

(2005). Building healthier hearts: Ireland’s cardiovascular strategy (Microsoft PowerPoint presentation). Retrieved from http://www.tohm.ie/download/pdf/evpaper_yach_fitz.pdf

26.

Giddens

(1984). The constitution of society: Outline of the theory of structuration. Cambridge, England: Polity Press.

27.

Greenwood

Hinings

C. R.

(1996). Understanding radical organizational change: Bringing together old and new institutionalism. Academy of Management Review, 21, 1022-1054.

28.

Hattrup

Jackson

S. E.

(1996). Learning about individual differences by taking situations seriously. In Murphy

K. R.

(Ed.), Individual differences and behavior in organizations (pp. 507-547). San Francisco, CA: Jossey-Bass.

29.

Holt

Armenakis

Field

Harris

(2007). Readiness for organizational change: The systematic development of a scale. Journal of Applied Behavioral Science, 43, 232-255.

30.

Jansen

J. J. P.

Van den Bosch

F. A. J.

Volberda

H. W.

(2005). Managing potential and realized absorptive capacity. How do organizational antecedents matter? Academy of Management Journal, 48, 999-1015.

31.

Jarzabkowski

(2008). Shaping strategy as a structuration process. Academy of Management Journal, 51, 621-650.

32.

Johns

(2006). The essential impact of context on organizational behavior. Academy of Management Review, 31, 396-408.

33.

Johnson

(1987). Strategic change and the management process. Oxford, England: Blackwell.

34.

Johnson

Duberley

(2000). Understanding management research: An introduction to epistemology. London, England: Sage.

35.

Judge

Bowler

Douglas

(2006). Preparing for organizational change: Evolution of the organizational capacity for change construct. Academy of Management Best Paper Proceedings, 1-6.

36.

Langley

(1999). Strategies for theorizing from process data. Academy of Management Review, 24, 691-704.

37.

Lega

(2008). The rise and fall(acy) of clinical directorates in Italy. Health Policy, 85, 252-262.

38.

Lewin

(1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, June, 5-41.

39.

Llewellyn

(2001). “Two way windows”: Clinicians as medical managers. Organization Studies, 22, 593-623.

40.

Martin

G. P.

Currie

Finn

(2008). Leadership, service reform and public-service networks: The case of cancer-genetics pilots in the English NHS. Journal of Public Administration Research and Theory, 19, 769-794.

41.

McDermott

Keating

M. A.

(2010). Creating a climate for service improvement through role structures. In Braithwaite

Hyde

Pope

(Eds.), Culture and climate in health care organizations (pp. 174-184). Hampshire, UK: Palgrave Macmillan.

42.

Montgomery

Oliver

A. M.

(2007). A fresh look at how professions take shape: Dual-directed networking dynamics and social boundaries. Organization Studies, 28, 661-687.

43.

National Health Strategy Consultative Forum. (2001). National health strategy consultative forum subgroup report: Service delivery and HR. Dublin, Ireland: Department of Health and Children.

44.

Parker

S. K.

Williams

H. M.

Turner

(2006). Modeling the antecedents of proactive behaviour at work. Journal of Applied Psychology, 91, 636-652.

45.

Patterson

M. G.

West

M. A.

Shackleton

V. J.

Dawson

J. F.

Lawthom

Maitlis

Robinson

D. L.

(2005). Validating the organizational climate measure: Links to managerial practices, productivity and innovation. Journal of Organizational Behavior, 26, 379-408.

46.

Payne

Williams

(2005). Generalization in qualitative research. Sociology, 39, 295-314.

47.

Pettigrew

A. M.

(1985). The awakening giant: Continuity and change in ICI. Oxford, England: Basil Blackwell.

48.

Pettigrew

A. M.

(1997). What is a processual analysis? Scandinavian Journal of Management, 13, 337-348.

49.

Pettigrew

A. M.

Ferlie

McKee

(1992). Shaping strategic change. Making change in large organizations: The case of the National Health Service. London, England: Sage.

50.

Pettigrew

A. M.

Woodman

R. W.

Cameron

K. S.

(2001). Studying organizational change and development: Challenges for future research. Academy of Management Journal, 44, 697-713.

51.

Rousseau

D. M.

Fried

(2001). Location, location, location: Contextualizing organizational research. Journal of Organizational Behavior, 22, 1-13.

52.

Schneider

White

S. S.

Paul

M. C.

(1998). Linking service climate and customer perceptions of service quality: Tests of a causal model. Journal of Applied Psychology, 83, 150-163.

53.

Strauss

Schatzman

Bucher

D. E.

Sabshin

(1963). The hospital and its negotiated order. In Fredison

(Ed.), The hospital in modern society (pp. 147-169). New York, NY: Free Press of Glencoe.

54.

Weitzman

Miles

(1995). Computer programs for qualitative data analysis: A software sourcebook. Thousand Oaks, CA: Sage.

55.

Yin

R. K.

(2003). Case study research: Design and methods (3rd ed.). London, England: Sage.