HealthCare Excellence

Many scholars increasingly suggest adopting a paradox lens to study organizations. They consider paradoxes as integral to organizations (Clegg, Vieira da Cunha, & Pina e Cunha, 2002; Ford & Backoff, 1988; Lewis, 2000; Luescher & Lewis, 2008), in which paradox is defined as an operation that implies the conditions for its possibility and impossibility (Ortmann, 2004). These works, however, remain vague on what "integral" means. Do organizations need to handle paradoxes or are they manifestations of handling paradoxes themselves? We argue that organizations represent manifestations of paradoxes and develop practices of handling paradoxes. To illustrate this claim, we draw on an in-depth case study on decision-making in a pluralistic context. First, the study demonstrates that a paradox underlies decision-making in pluralistic contexts: The autonomy of organizational members who pursue diverse interests requires decisions which span professional boundaries; at the same time, the autonomy of organizational members impedes such decisions (Bate, 2000; Ericson, 2001; Glouberman & Mintzberg, 2001; Jarzabkowski & Fenton, 2006; Lozeau, Langley, & Denis, 2002). Second, results from a decision premise (Luhmann, 2000) analysis show that organizational members apply a "bilateral-situative" decision-making practice, a both/and approach which both acknowledges their autonomy and enables decisions across boundaries. A decision-premise focuses on who decides on what, when, and how within an organization. A decision-premise specifies what an organization regards as "organizational". To argue our claim theoretically, we draw on the concept of "bootstrapping" by American sociologist Barry Barnes (Barnes, 1983) which addresses the issue of self-reference in reproducing social phenomena. "Bootstrapping" means that ongoing flows of activities, like actions, communications or decisions, pass through a label - like "organizational" - that filters activities as to whether they belong to the label, and then attaches this label to the activity so that it counts as expressing the label, i.e. as belonging to or expressing "organizational". Such a label like "organizational" allows to distinguishing what is organizational, while all other activities are disregarded. The label in turn emerges through this ongoing flow of activities, in which the process consists of activities that result endogenously from the same process as well as from exogenous inputs. "Bootstrapping" conceptualizes the way of how decisions and decision-premises relate with one another, either in a way that reproduced the label or undermines it over time. Our empirical results exemplify the former, i.e. the reproduction that allows handling the paradox of decision-making in a pluralistic setting. Thus, we argue that a pluralistic organization is a manifestation of a paradox, rather than having a paradox. The latter alternative in which the label is undermined over time, would involve a continuous change of the label or an episodic attempt of altering it. This study speaks to three bodies of literature: First, our study speaks to pluralistic organization by arguing that they are manifestations of paradox and that they developed specific ways of handling them. Second, the empirical results exemplify an organizational perspective on paradoxes, whereas most paradox literature focuses in individuals and groups. Third, bootstrapping offers an insight into how two components of a duality relate over time through feedback. This conceptualization complements the existing view of duality (Farjoun, 2010; Feldman & Pentland, 2003). These works elaborate on what one component serves for the other component, thus representing a functional perspective. In comparison, our conceptualization of bootstrapping with decision-premises as the label captures not only such functions but also opens the pathway to pursue the opposite, a disfunctional relation. Bootstrapping allows explaining reproducing and changing a temporal social order as a self-referential process.

Exploring the interrelated practices that lead to the failure of a strategic change initiative in a large university hospital in Switzerland.

Taking a process perspective, we explore stabilizing and changing. Building on insights of routines, improvising and changing scripts, we on the relationship between a change initiative and the daily organizing and explore the question: how is stabilizing of a change initiative accomplished while it attempts to alter daily organizing in which it is embedded? Within a single longitudinal case of introducing a new surgical treatment practitioners explained their conducting change as "sub-cutane change". We interpret sub-cutane change as an emergent process pattern to conduct a change initiative within an organizational setting like surgery that requires a high degree of stable practice. Sub-cutane change addresses the topic of simultaneously stabilizing a change initiative while changing the daily organizing in which it was embedded. An important insight of the presented case is that both require mutual protection from each other. Changing is precarious because it means to interrupt ongoing daily practice. But as the organization continues operating, it enacts that which is to change. Continued operating provides functional legitimacy that can block the change initiative. As a conclusion, stabilizing in change is understood as an ongoing accomplishment.