Strategic Flexibility in Not-For-Profit Acute Care Hospitals

312 Pages·2016·2.76 MB·English

University of Wisconsin Milwaukee
UWM Digital Commons
Theses and Dissertations
May 2014
Strategic Flexibility in Not-For-Profit Acute Care
Hospitals
Donna Fe Jamieson
University of Wisconsin-Milwaukee
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Jamieson, Donna Fe, "Strategic Flexibility in Not-For-Profit Acute Care Hospitals" (2014).Theses and Dissertations. 697.
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STRATEGIC FLEXIBILITY IN NOT-FOR-PROFIT ACUTE CARE HOSPITALS

by

Donna F. M. Jamieson

A Dissertation Submitted in
Partial Fulfillment of the
Requirements for the Degree of

Doctor of Philosophy
In Nursing

at
The University of Wisconsin – Milwaukee
May 2014
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ABSTRACT
STRATEGIC FLEXIBILITY IN NOT-FOR-PROFIT ACUTE CARE HOSPITALS
by
Donna F. M. Jamieson
The University of Wisconsin-Milwaukee, 2014
Under the Supervision of Professor Rachel Schiffman

Despite multiple industry cycles of rapid and complex changes in the last three decades,
the body of research in health care services strategy has not addressed the idea of
strategic flexibility, that is, when and how should strategy evolve under conditions of
environmental turbulence. Strategic flexibility has been defined in the literature as the
ability to adapt to rapidly changing conditions by leveraging internal resources and
competencies to effectively compete. With increasing scope of responsibility in both
nursing and non-nursing functional areas, nurse executives have not only participated as
members of the executive team in setting strategic direction for hospitals but also
developed specific strategic agendas for how nursing contributes to the overall value of a
hospital’s services. With few studies available to guide practice development, a paucity
of information exists on how nurse executives should conduct strategic planning and
what particularly leads to effective adaptation. A multi-case study research approach
explored how acute care hospitals manifested strategic flexibility in response to changing
conditions and how nurse executives played a role in developing and using those
flexibilities. Seventeen nurse executives from seven acute care hospitals in a midwestern
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metropolitan area participated in the study. Using interview data, document analysis and
field observations, a combination of operational, tactical and strategic level types of
strategic flexibility were noted at all seven hospitals. Strategic flexibility was associated
with external environmental conditions related to policy changes, market dynamics and
consumer perspectives. External conditions were associated with three internal conditions
related to human resources, facility renovations and hospital culture. Nurse executives
demonstrated various examples of tactical and strategic flexibilities, playing a major role
in developing strategic flexibility. An unexpected finding was the discovery of five
subcategories of tactical flexibilities. Results from the study provide a beginning
description of strategic flexibility in hospitals. Examples of strategic flexibility identified
in this study can be used to operationally define and, thus, measure strategic flexibility.
The possibility of measuring strategic flexibility allows for other empiric studies of how
strategic flexibility influences hospital performance such as patient care outcomes and
quality of care.

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Copyright by Donna F. M. Jamieson, 2014
All Rights Reserved

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Dedication

This dissertation is dedicated to my husband and best friend, Ed Jamieson, and to
our sons, Colin and Dan. I would not have achieved this goal without your unwavering
support, patience, encouragement and humor through the years. Thank you for sharing
this journey with me.

To my parents, Carolina and Angeles Mariano, who have instilled the value of
learning and hard work in me --- your guidance helped me set the foundation and
fortitude for this kind of endeavor. I am deeply grateful for your support through the
years.

To my sisters, brothers, sisters-in law --- for your words of encouragement ---
your support meant a great deal to me.

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Table of Contents
CHAPTER PAGE

Chapter 1 ...................................................................................................................................... 1
Introduction ............................................................................................................................................................ 1
Problem Statement .......................................................................................................................................... 4
Purpose of Study ............................................................................................................................................. 6
Conceptual Framework ................................................................................................................................. 8
Research Questions ...................................................................................................................................... 15
Definition of Terms ...................................................................................................................................... 15
Significance..................................................................................................................................................... 22
Summary .......................................................................................................................................................... 24
Chapter 2 .................................................................................................................................... 27
Review of Literature .......................................................................................................................................... 27
Strategic Flexibility ...................................................................................................................................... 28
Defining Strategic Flexibility .................................................................................................................... 29
Typology and Sources of Strategic Flexibility .................................................................................... 39
Conditions Requiring Strategic Flexibility ........................................................................................... 60
Hospital Behaviors During Periods of Environmental Change ...................................................... 62
Chapter 3 .................................................................................................................................... 66
Methods ................................................................................................................................................................. 66
Organizational Case Studies as a Method for Studying Strategic Flexibility in Hospitals .... 66
Research Design ............................................................................................................................................ 68
Defining the Study Population .................................................................................................................. 71
Sampling .......................................................................................................................................................... 72
Gaining Access .............................................................................................................................................. 79
Collecting Data for Case Study Evidence ............................................................................................. 80
Data Sources ................................................................................................................................................... 85
Procedures ....................................................................................................................................................... 86
Analysis and Synthesis of Data ................................................................................................................ 94
Ethical Considerations ................................................................................................................................. 99
Trustworthiness........................................................................................................................................... 101
Study Limitations ....................................................................................................................................... 102
Summary ....................................................................................................................................................... 104
Chapter 4 ................................................................................................................................. 106
Results ................................................................................................................................................................. 106
Sample ................................................................................................................................................................ 106
Coding Results ................................................................................................................................................. 112
Case Narrative – Hospital 09443 ................................................................................................................ 115
Case Narrative – Hospital 19444 ................................................................................................................ 128
Case Narrative – Hospital 40055 ................................................................................................................ 140
Case Narrative – Hospital 46920 ................................................................................................................ 147
Case Narrative – Hospital 79556 ................................................................................................................ 156
Case Narrative – Hospital 93654 ................................................................................................................ 166
Case Narrative – Hospital 96783 ................................................................................................................ 178
Summary ............................................................................................................................................................ 189
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CHAPTER PAGE
Chapter 5 ................................................................................................................................. 191
Cross-case Analysis ........................................................................................................................................ 191
Research Question 1: How do hospitals manifest strategic flexibility? ......................................... 191
Research Question 2: What external environmental conditions are related to the development
of strategic flexibilities in hospitals (given environmental dynamism, hypercompetitive states,
complex changes, conditions of ambiguity, conditions of unpredictability)? .............................. 205
Research Question 3: What internal environmental conditions influenced the development of
strategic flexibilities? ..................................................................................................................................... 216
Research Question 4: What role do nurse executives play in developing strategic flexibility?
............................................................................................................................................................................... 218
Research Question 5: How do nurse executives develop strategic flexibility in their
organizational function? ................................................................................................................................ 221
Summary ............................................................................................................................................................ 222
Chapter 6 ................................................................................................................................. 224
Discussion of Findings .................................................................................................................................. 224
Key Findings ..................................................................................................................................................... 224
Implications for Nursing Practice .............................................................................................................. 242
Study Strengths and Limitations ................................................................................................................. 247
Recommendations for Future Research ................................................................................................... 251
Summary ............................................................................................................................................................ 254
References ............................................................................................................................... 256
Appendix A: Screening Procedure for Hospital Case Study Recruitment .................................... 274
Appendix B: Screening Procedure for Hospital Nurse Executive Recruitment .......................... 276
Appendix C: IRB Approval Letter ............................................................................................................. 278
Appendix D: Interview Protocol ................................................................................................................. 279
Appendix E: Revised Interview Questionnaire ...................................................................................... 284
Appendix F: Document Data Collection and Tracking Form ........................................................... 287
Appendix G: Direct Observation Documentation Form ..................................................................... 288
Appendix H: Cross-case Analytical Procedures - Worksheets ......................................................... 289

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LIST OF FIGURES
PAGE
Figure 1: External and internal environmental conditions that influence
need for strategic flexibility in acute care hospitals…………...... 9

Figure 2: Common constructs identified in strategic flexibility literature… 44
Figure 3: A summary of typologies and sources of strategic flexibility….. 47
Figure 4: Nested sample design…………………………………………… 70
Figure 5: Coded themes – number of sources and references per theme…. 113
Figure 6: Coded themes for all hospital participants……………………… 114
Figure 7: Space design for physician interaction with hospital executives.. 165
Figure 8: External environmental conditions reported by nurse executives. 206

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LIST OF TABLES

TABLE Page

Table 1: Definitions – Strategic flexibility……………………….…… 31

Table 2: Strategic flexibility typologies reported in literature.…….…. 45

Table 3: Two-stage screening protocol for hospital participation……. 74

Table 4: Inclusion criteria for hospital selection process……………... 75

Table 5: Two-stage screening process for NE participation………….. 78

Table 6: Checklist for information needs with each research question. 82

Table 7: Interview protocol, questions and documentation………..…. 88

Table 8: List of interview questions…………………………………... 90

Table 9: Topic guide for obtaining background information……...….. 91

Table 10: Document authentication analysis protocol……………….… 93

Table 11: Direct observation guide…………………………………..… 94

Table 12: Cross-case analytical procedure…………………………….. 97

Table 13: Service designation documented by State Department of
Public Health……………………………………………..…. 107

Table 14: Hospital networks, status and ownership……………..….…. 108

Table 15: Nurse executive tenure…………………………….….….…. 110

Table 16: Nurse executive educational background……………..…..… 111

Table 17: Cross-case analysis of operational flexibilities……………… 193

Table 18: Tactical flexibility – process/routine oriented flexibilities….. 197

Table 19: Tactical flexibility – role definition or role redefinition
oriented flexibilities…………………………………....……. 198

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