Barbara Bigelow

Research on Strategic Management in Nonprofit Organizations Synthesis, Analysis, and Future Directions

This article presents a review and analysis of empirically based research on strategic management in nonprofit organizations reported in major journals from 1977 to the present. Although much work has been done on strategy formulation, types of strategies pursued, and implementation in nonprofits, significant gaps exist in our knowledge. Few explicit connections have been made among research studies, contributing to fragmentation of the field. Crucial relationships among strategy components are missing, and links between these components and organizational performance have yet to be made. The article analyzes what is known about strategic management in nonprofits and identifies questions for future research.

The implementation of total quality management in hospitals: how good is the fit?

Total quality management has become popular among hospitals because of its promise to reconcile trade-offs between cost and quality. However, assumptions inherent in TQM may not translate to the hospital environment: hierarchical management control over the technical core and the dominance of rational decision making. This article considers these two assumptions and suggests that the application of TQM to hospitals take them into account because they may compromise its success.

Why Don't They Do What We Want? an Exploration of Organizational Responses to Institutional Pressures in Community Health Centers

Throughout the last two decades, the nonprofit sector has emerged as a major provider of basic health and human services and as a prime implementor of certain public policies (Kramer, 1981; Saidel, 1991; Salamon, 1987; Smith and Lipsky, 1993). At the same time, resource suppliers to nonprofit organizations, such as government agencies at local, state, and federal level, have been under pressure to demand that non-profits reduce costs and increase efficiency and productivity. However, nonprofit response to such demands is not well understood despite the fact that public administrators, policy makers, and foundation managers, among others, find that implementing their goals is increasingly intertwined with the work of nonprofit organizations (Saidel, 1991). Our purpose in this article is to examine what specific organizational and environmental characteristics shape nonprofit responses to these downsizing demands. Through a study of budget cuts in four community health centers, this research demonstrates that conformity through compliance - a response often anticipated by funding sources - is only one among four responses made in the face of pressures for improved efficiency and productivity that accompanied the cuts. Nonprofit organizations operate in environments characterized by uncertain relationships between means and ends. In such institutional environments, legitimacy, not efficiency, is critical to an organizations ability to secure vital resources (Meyer and Rowan, 1977). Organizations gain legitimacy through conformity with prevailing norms, practices, and beliefs of multiple constituencies (Meyer and Rowan, 1977; Zucker, 1983), and through organizational responses to institutional pressures. The nature of these pressures has been well defined (see, for example, DiMaggio and Powell, 1983) and their effect on the diffusion of different organizational structures and processes is well documented (Burns and Wholey, 1993; Fligstein, 1979; Tolbert and Zucker, 1983). However, implicit in much of this work is an assumption of organizational passivity and conformity in the face of institutional pressures (Covaleski and Dirsmith, 1988a). Oliver (1991) developed a conceptual framework of organizational response to institutional pressures that directly challenges this assumption of passivity. First, organizations may conform or acquiesce. Second, they may compromise, particularly in the face of conflicting demands. This response includes the partial conformity described by Scott (1983) in which health care organizations meet at least minimum standards set by federal agencies. Third, organizations may attempt to avoid institutional pressures through, for example, symbolic compliance (Meyer and Rowan, 1983) where organizations conceal nonconformity or minimize external evaluation. Fourth, organizations may actively resist pressures or, fifth, attempt to manipulate or change them. The analysis in this article builds directly on Olivers (1991) framework. Both Covaleski and Dirsmith (1988a; 1988b) and Oliver (1991) suggest that internal characteristics and interorganizational relationships combine in unique ways to produce this variety of responses. In this article, we investigate organizational responses to one form of institutional pressure - the expectations accompanying budget cuts demanded of community health centers. Although funders do not dictate what cuts should be made, they use coercive pressures in the form of productivity standards or staffing levels to encourage certain ends. However, community health centers are not dependent solely on funders for legitimacy and resources. As a consequence, the conformity desired by funders may be problematic as centers respond not only to pressures emanating from them but from other critical constituencies such as communities, clients, and others. In the next section, three characteristics of community health centers likely to affect organizational response are described: intraorganizational conflict, organizational coalitions, and interorganizational conflict. …

Evidence-based management in health care organizations: a cautionary note.

Background: Health care managers are urged to adopt evidence-based management as a new and exemplary decision-making process. Three assumptions underlie advocacy for the practice: (a) Decisions based on evidence will yield anticipated results, (b) these results are generalizable across organizations, and (c) evidence is objective and context free. Purpose: This article explores evidence-based management through contextual and conceptual lenses that question these underlying assumptions. Methods: A review of extant literature on evidence-based management was conducted. Findings: Calls for evidence-based management are based mostly on conceptual arguments that it constitutes best practice because there is not yet any empirical research that demonstrates its effectiveness. We raise a cautionary note about the assumptions underlying the calls for evidence-based management. Given the complexity of decision making and of the health care environment, as well as differences among health care organizations, decisions do not necessarily lead to expected outcomes, and results may not be replicable across organizations. Moreover, evidence is an artifact of social interactions and limited by the difficulties inherent in studying complex organizational phenomena. Conclusion: Research is needed into the diffusion of evidence-based management in health care and into the results achieved by organizations that used the practice compared with organizations that did not. Practice Implications: Managers should use all available information and data when planning and implementing decisions, and evidence from research should play a role in that. At the same time, in a turbulent and uncertain environment, creativity and risk taking also will be important, and unanticipated outcomes may result from, among other factors, limits on human cognition, unknowable differences in initial conditions in organizations, and adaptive responses to change as it is implemented.

Professionalizing and Masculinizing a Female Occupation: The Reconceptualization of Hospital Administration in the Early 1900s

This paper examines the earliest boundary work for a female-dominated occupation that portrayed men rather than women as the appropriate practitioners. According to the concept of gender primacy, men would not enter a female-dominated occupation in large numbers because it is associated with gender essentialism. Hospital administration is one of the rare female occupations that did masculinize. Our analysis of archival texts on hospital administration in the early 1900s describes that in establishing a jurisdiction, body of knowledge, and educational requirements, the male-dominated professional association created a male sex boundary. Extracting and elaborating functions consistent with gender primacy and sloughing off functions associated with gender essentialism reframed the occupation as male. Rhetorical use of gender created a male image of the generic practitioner and the occupation, while an internal boundary segregated women within the occupation. The study points to differences in how occupations feminize and masculinize and suggests the latter does not occur solely in response to societal factors, as has been assumed, but can originate within the occupation.

The more things change, the more they stay the same.

For decades, the hospital environment has been described as turbulent and hostile. At the same time, the transfer of business practices into hospitals has been advocated, accompanied by the largely untested assumption that these practices are crucial to performance and even survival. As this pattern became entrenched, the accumulated knowledge gained within the industry of managing in a hostile and turbulent environment has been overlooked. We argue that it is time to question the pattern.

Reengineering: Deja Vu All Over Again

There is growing interest among hospitals in reengineering. It promises dramatic improvements in performance: Costs will be reduced while work processes, productivity, and patient care will all improve. A review of the health care literature on reengineering shows that little evidence exists to support its claims. This article critiques the existing literature on reengineering and addresses the conundrum hospital executives encounter when faced with the decision to adopt a new management technique—such as reengineering—in the absence of proof of its efficacy.

Toward the creation of an institutional logic for the management of hospitals: efficiency in the early nineteen hundreds.

This research focuses on the creation of an institutional logic—efficiency—and on its organizing principles of standardization and business practices through a study of the American Hospital Association and its publication, the Modern Hospital. In the early years of the 20th century, efficiency began to emerge as a first institutional logic for the management of hospitals. The term was defined broadly, encompassing not only economy but also quality and breadth of services, as well as access to care. This early emphasis on efficiency foreshadowed three issues that affect health policy and hospital management to this day: the pressure on hospitals to introduce new technology while containing cost, the assumption that hospitals should act like businesses, and the practice of offering large hospitals as the model for other providers.

Corporate political strategy: incorporating the management of public policy issues into hospital strategy.

Hospitals engage in a variety of strategies designed to anticipate, shape, and respond to public policy issues. This article describes corporate political strategy and argues for its need throughout a public policy issues life cycle.

In their own words: how hospitals present corporate restructuring in their annual reports.

Hospitals operate in an environment with strong institutional pressures, in which legitimacy is critical to an organizations access to resources. In such an environment, organizations can increase their legitimacy by engaging in activities or discussing them in a manner that signals that the organization adheres to values held by its costituents. One important symbol of organizational actions or intentions is the formal organizational structure. When hospitals began to adopt a corporate structure in the early eighties, the way in which they presented this decision to the public was as important as the technical merits of the decision itself. This study investigates, through an analysis of annual reports, what hospitals signaled about their adoption of a corporate structure. The findings suggest that through restructuring, hospitals signaled that they were in line with practices advocated in the industry and literature (e.g., adhering to business values, protection of assets, or increasing patient services). By presenting multiple reasons for restructuring, hospitals could signal their attention to the needs of various constituents, and by touching only briefly on each reason, they could ignore the potential conflict between demands such as lower hospital cost and increased services. The findings also suggest that the first hospitals to adopt a corporate structure sought to educate constituents about restructuring by devoting a greater share of their annual report to the topic than later adopters and by enumerating a larger number of anticipated benefits from the structure, which would have enhanced the innovations legitimacy in the early years.