Exploring multidimensional PMM reform within the complex dynamics of multi level institutions and constrained agency autonomy: A case study of a public hospital in China

Abstract

Since the emergence of New Public Management (NPM) and its goal of modernising public healthcare management, a significant body of management accounting literature has explored how the interplay of contextual factors as well as actors from different levels influences management accounting developments, mainly in the Western context. Building on the extant literature, this thesis aims to advance the current knowledge by using an institutional logic perspective to deconstruct the complex interests at play in shaping the performance measurement and management (PMM) of public hospitals at the social, field, organisational, and intra-organisational levels in the context of China’s public hospital management. Therefore, this thesis explores how the multidimensional performance measurement and management (PMM) reforms are shaped by the complex and dynamic interplay between multi-level institutions and the constrained autonomy of agents within Chinese public hospital setting—by adopting an Institutional Logics Perspective (ILP). Employing a case study in a tertiary hospital in the southwest of China, this thesis aims to answer three research questions: 1) How are PMM transformation and institutional complexity dynamics interrelated? 2) How do the organization respond to the institutional complexity dynamics in their environment through PMM reform? and 3) How is the intra-organisational institutionalisation of the PMM reform shaped by situated actors within the organisation? The findings of this research reveal the intricate and multifaceted affects by the coordination between the emerging managerial logic at Chinese public healthcare field and the high-level dominating state logic on shaping the field-level PMM transformation. This study highlights the fundamental influences of institutional complexity at the field level on the proactive managerial response to initiate a PMM reform, as observed in the case hospital. Additionally, the heterogeneity in departmental professional reputation, operational intricacy, and leadership paradigms potentially steers internal medical departments towards diverse reform response strategies and then culminates in internal complexity by internalising diverse departmental PMM practices. Then the inconsistency between the managerial objectives and the actual departmental practises concerning the reforms might result in a means-end decoupling of this PMM reform. The primary contribution of this study is its extension of the contextual explanation of institutional logics beyond Western public healthcare settings. Drawing on a multi-level study of a case hospital, this research presents a theoretical framework to deconstruct the pathway of the PMM reform across various internal units. This framework highlights the fundamental influences of partial autonomy on causing internal dynamics and diversity of different medical departments in their responses to and adoption of the reform. The study contends that the heterogeneity of subunits poses challenges to designing and implementing a uniform organizational reform aimed at addressing external institutional complexity dynamics. Crucially, an exclusive emphasis on addressing the multifaceted external institutional pressures, without considering subunit diversity, may lead to a 'means-end decoupling' during the reform of public organizations. Overall, this research sheds light on the complex interplay between institutional complexity, partial autonomy, and PMM reform in public hospitals, highlighting the need for nuanced approaches that recognising the diverse contexts and cultures in which such reforms are implemented. The findings have important implications for policy makers and management seeking to design and implement effective PMM reform in healthcare sectors across different cultural and institutional contexts.

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Identifiers

ORCID for LINXI SHI: orcid.org/0000-0001-5092-607X

ORCID for Pingli Li: orcid.org/0000-0001-5020-9126

ORCID for Krish Vithana: orcid.org/0000-0001-9976-7399

ORCID for Bai Xue: orcid.org/0000-0001-8792-2021

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