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Have management papers ever changed practice in healthcare?

Guest blogger Trish Greenhalgh takes on a Twitter challenge

Sir Muir Gray, of evidence-based medicine fame, is a man who speaks his mind – often in 140 characters or fewer. “Show me a paper by a management academic,” he Tweeted, “that has changed the way we deliver health services” [and, implicitly, improved patient outcomes].


Part of me agreed with him, but I’m married to a management academic (“Oops sorry, better man than me,” Muir backpedalled), who helped me rise to Muir’s challenge.

We kicked off with a paper almost every clinician has heard of:

Image Credit: Julie Rybarczyk

Kaplan and Norton’s ‘balanced scorecard’, published in Harvard Business Review in 1992 and cited over 8000 times since [1]. The scorecard was aimed at company directors who wanted some quick (and, one is tempted to suggest, dirty) metrics to monitor what their customers thought of them and where they should direct their efforts for the future. It has certainly changed practice (many healthcare organisations use it), but we were not overly sold on its transferability to the healthcare setting.


In danger of winning the point but losing the principle, we tried to think of papers in management journals (which consist mainly of studies undertaken on US private-sector, product-oriented firms) whose findings had been applied to public sector, service-oriented organisations in the UK in a way that improved patient-relevant outcomes. We pretty much drew a blank.

One paper – Ramiller and Pentland’s critique of ‘variables centred’ organisational research [2] – gave a clue as to why.  Abstracted variance models aimed at producing generalisable truths about how organisations behave may appear scientific and rational (and promise findings that could be ‘rolled out’ to new settings), but in reality may have limited value since they divert the focus away from people taking action. These authors argue for a case study approach to complex change, in which human actors and action remain in frame, and the link between ‘input’ and ‘outcome’ is made using here-and-now narrative rather than abstracted, logicodeductive reasoning.


Talking of the narrative form in organisational research, there are a number of classics in this genre, including


  • Weick on sensemaking. Staff need to make collective sense of organisational life; encouraging this sensemaking process is key to successful change efforts [3].


  • Tsoukas [4] and Brown and Duguid [5] on organisational knowledge. Knowledge is embodied, socially developed and – to a metaphor originally coined by Wittgenstein – “rides along the rails laid down by shared practice”. This view of knowledge has been applied by Gabbay and le May in their brilliant work on ‘mindlines’ in health professionals [6].


  • Van de Ven on the longitudinal case study method for organisational innovation [7]. However carefully you plan, innovation in healthcare organisations is invariably a messy, non-linear process that takes years rather than months and is characterised by shocks and setbacks. Again, don’t expect to document predictable and reproducible links between inputs and outcomes. My team’s systematic review of diffusion of innovations in healthcare drew heavily on Van de Ven’s empirical studies [8].


  • Feldman and Pentland on organisational routines [9]. Routines are recurring patterns of interpersonal interaction that confer stability in an organisation but which also offer scope for change (when human actors choose to enact the routine differently). My team used this approach to surface the sophisticated ‘hidden work’ of receptionists in assuring medication safety in healthcare [10].


Incidentally, for a feisty argument over whether ‘variables-centred’ or ‘actor-centred’ paradigms are more robust, see Pfeffer’s Academy of Management Annual lecture from 1993 [11] and Van Maanen’s insouciant response [12].


We found many papers we wished had changed practice but probably hadn’t. For example:


  • Fulop’s team showed pretty decisively that hospital mergers don’t save money [13].
  • Currie and Guah predicted (accurately) the failure of England’s ill-fated £12.7 billion National Programme for Information Technology if policymakers continued to ignore stakeholders’ conflicting institutional baggage [14].


Image Credit: Adrian Boliston

Do healthcare policymakers take any notice of academic papers which warn that current approaches are unwise? My team didn’t think so. We drew on Tsoukas’ model of organisational knowledge to explain why [15].


A number of management papers emphasised the complex and context-bound nature of organisational phenomena. For example:


  • Hawe and colleagues theorised complex interventions as events in complex systems [16]
  • Lanham et al considered healthcare teams as complex systems and quality as an emergent property of those systems [17]
  • Bate and colleagues looked at social movements as a force for change [18]. These movements – from feminism to the Arab Spring – work by linking an emerging identity (being part of the movement says something about who we are) with collective action (movements organise and do things). But they are inherently non-linear and cannot be ‘controlled’.

The topic of leadership is done to death in healthcare journals but most management academics have little interest in it, perhaps because it’s an example of a variable that has been abstracted from the person who has it!  But one paper – on the subtle approach of ‘tempered radicalism’ by Myserson and Scully – made it onto our list [19].

I’ve been avoiding Muir Gray recently. Whilst the exercise of attempting to “find a paper by a management academic that had changed practice and benefited patients” produced many insights into why organisational change in healthcare is difficult and unpredictable, the links between these papers and hard outcomes in healthcare were usually tenuous. If I were being pedantic, I would suggest that this is because Muir’s question implies a deterministic link between inputs (academic papers) and outcomes (patient benefits) whereas most of the literature listed above is theoretically incommensurable with such a link. But I suspect I should concede defeat and go buy him a drink. Or at least, give his book – on how to get it right when building healthcare systems – a gentle plug [20].

Acknowledgment: This blog is based on a discussion on Twitter and includes
various papers suggested by my followers.

Trish Greenhalgh is Professor of Primary Health Care at Barts and the London School of Medicine and Dentistry, London, UK, and also a general practitioner in north London.

1.         Kaplan RS, Norton DP: The balanced scorecard–measures that drive performance. Harvard Business Review 1993, Jan-Feb:71-147.

2.         Ramiller N, Pentland B: Management implications in information systems research: the untold story. Journal of the Association for Information Systems 2009, 10(6):474-494.

3.         Weick KE: Sensemaking in organizations. Thousand Oaks, CA:    : Sage; 1995.

4.         Tsoukas H: What is organisational knowledge. Journal of Management Studies 2001, 38(7):973-993.

5.         Brown JS, Duguid P: Knowledge and organization: A social practice perspective. Organization Science 2001, 12(2):198-213.

6.         Gabbay J, le May A: Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004, 329(7473):1013.

7.         Van de Ven AH: Central probelms in the management of innovation. Management Science 1986, 32(5):590-607.

8.         Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organisations: systematic literature review and recommendations for future research. Milbank Q 2004, 82  581-629.

9.         Feldman MS, Pentland BT: Reconceptualizing organizational routines as a source of flexibility and change. Administrative Science Quarterly 2003, 48:94-118.

10.       Swinglehurst D, Greenhalgh T, Russell J, Myall M: Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. BMJ 2011, 343:d6788.

11.       Pfeffer J: Barriers to the advance of organizational science: paradigm development as a dependent variable Academy of Management Review 1993, 18(4):599-620.

12.       Van Maanen J: Style as Theory. Organizational Science 1995, 6:133-143.

13.       Fulop N, Protopsaltis G, Hutchings A, King A, Allen P, Normand C, Walters R: Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. BMJ 2002, 325(7358):246.

14.       Currie WL, Guah MW: Conflicting institutional logics: a national programme for IT in the organisational field of healthcare. Journal of Information Technology 2007, 22:235-247.

15.       Greenhalgh T, Russell J, Ashcroft RE, Parsons W: Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History. Milbank Q 2011, 89(4):533-563.

16.       Hawe P, Shiell A, Riley T: Theorising interventions as events in systems. American journal of community psychology 2009, 43(3-4):267-276.

17.       Lanham HJ, McDaniel RR, Jr., Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting P: How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Joint Commission journal on quality and patient safety / Joint Commission Resources 2009, 35(9):457-466.

18.       Bate P, Robert G, Bevan H: The next phase of healthcare improvement: what can we learn from social movements? Quality & safety in health care 2004, 13(1):62-66.

19.       Myerson DE, Scully MA: Tempered radicalism and the politics of ambivalence and change. Organization Science 1985, 6(5):585-600.

20.       Gray JAM: How to build healthcare systems. Offox Press Ltd: Oxford; 2011.

  1. This was very thought-provoking and a great panoramic sweep. But given that much of health management is by clinical leaders, think there may be more of a research footprint than stated here. For instance, in one particular are of patient safety, you could track the influence of research in framing of the problem as priority for service (Charles Vincent on rate of avoidable harm in hosp to Nick Barber on medication errors in care homes to ethnographic studies on operating error/distractions); to relevant papers on safety cultures (theoretical – Waring/Currie – and development of tools – MAPSAF); to evaluation of programmes (eg Dixon-Woods on Michigan, Benning/Lilford on SPI); human factors research on teamworking, handover, system weaknesses; to service delivery interventions (from top-down HCAI targets to ward-based pharmacists to infection control nurses/isoloation wards in hospitals). Although hang on a minute, latter not very well evidenced at all…

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