HLTH 4100 Week 10 Organization Theory Critique Example

Why Did the Hospital Adopt a Discharge-Before-Noon Target? Contingency Theory and Institutional Theory Run Over the Same Decision, and What Each Misses

Student Name

Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

Instructor Name

Month Day, Year

Why Did the Hospital Adopt a Discharge-Before-Noon Target? Contingency Theory and Institutional Theory Run Over the Same Decision, and What Each Misses

The Episode Held Steady

Two years ago, our hospital adopted a goal that 35% of inpatient discharges occur before noon, added it to unit dashboards and later tied it to a quarterly bonus for nurse managers. The goal was presented as a way to free beds earlier in the day for emergency department patients. Earlier in this course, I found that the bonus moved discharge orders earlier without moving patients. This paper asks a prior question: why did the hospital adopt the target at all? It runs two organizational theories over the same decision, contingency theory and institutional theory, compares what each explains and identifies what each misses.

The Contingency Explanation

Contingency theory holds that there is no single best way to organize; effective organizations adapt their structures and practices to fit their environment, technology and tasks (Donaldson, 2001). Applied to this decision, the theory would explain the target as a fit between practice and environment. The hospital faced a specific problem: emergency department arrivals peak in the afternoon, when inpatient beds are fullest, because most discharges happen in late afternoon. Moving discharges earlier would align the supply of beds with the timing of demand. On this view, the target was a rational adjustment to a measured mismatch.

What it explains well. It explains why the target addressed timing rather than total discharges, and why it was attractive to leaders who saw the afternoon boarding peak in their data. There is some evidence that early discharge goals can be reached through redesign of rounds and discharge planning (Wertheimer et al., 2014), so the target was not implausible as a response.

The Institutional Explanation

Institutional theory holds that organizations often adopt structures and practices not because they are the most efficient but because they are considered legitimate in their field. DiMaggio and Powell (1983) described three pressures toward similarity, or isomorphism: coercive pressure from regulators and funders, normative pressure from professions and mimetic pressure, in which organizations facing uncertainty copy others that seem successful. Applied to this decision, institutional theory would point out that discharge-before-noon targets became popular among hospitals in the 2010s, appeared in conference presentations and consultant recommendations and were adopted by our own health system's other hospital before ours. Our leaders, uncertain how to fix boarding, may have adopted the target because respected peers had, not because they had analyzed whether it fit our hospital.

What it explains well. It explains why the target was adopted with a round number, 35%, that matched what other hospitals used rather than a number derived from our own data, and why it was measured by order time, the easiest metric to report, rather than departure time. It also explains why the target persisted after it failed to change departures: once adopted, a legitimate-looking practice is hard to abandon.

Points of Disagreement

The two theories disagree about what caused the decision. Contingency theory says the hospital adopted the target to fit its environment; institutional theory says it adopted it to look like a well-run hospital. They also disagree about what would have happened next. If the contingency explanation were right, leaders who noticed the target was not working would have changed it, because the point was fit. If the institutional explanation were right, the target would persist because its value was legitimacy, not results. The target has persisted for two years despite evidence that it did not move departures, which supports the institutional reading.

A Third Possibility: Internal Politics

A third explanation sits outside both theories. At the time the target was adopted, the hospital board had asked senior leaders for a visible response to rising emergency department boarding, which had been reported in the local newspaper. A discharge-before-noon target was quick to announce, easy to measure and familiar to board members who had seen it elsewhere. On this view, the target was adopted partly to show action to a governing body. That explanation overlaps with institutional theory, since legitimacy in the eyes of a board is part of what institutional pressures produce, but it emphasizes a particular audience and a particular moment rather than a general pressure in the field. It also explains the choice of a measure, order time, that would show progress quickly.

What Each Misses

Contingency theory misses why the specific form of the target, its round number and its order-time measure, came from outside rather than from the hospital's own analysis. It also cannot easily explain persistence after failure.

Institutional theory misses the real mismatch in timing that the target addressed. The hospital did have an afternoon bed problem, and leaders were not only seeking legitimacy. It also tends to treat leaders as imitators and to miss the internal politics, such as the need to show the board some action on boarding, that shaped the choice.

Neither theory explains how the target played out on the units, where expectancy and structure determined behavior. That is a reminder that macro-level theories explain why organizations adopt practices more readily than they explain what happens when practices meet the people who carry them out.

Using Both

The most complete account uses both theories. The hospital had a real fit problem that contingency theory identifies, and it chose a widely legitimated solution that institutional theory explains, without adapting the solution's form to its own setting. The lesson for a manager is practical: when adopting a practice that is popular in the field, ask both questions. Does it fit our specific problem, and are we adopting it partly because others have? If the second answer is yes, the organization should be especially careful to measure whether the practice works here, and willing to change it if it does not. Organizational researchers have long argued that the major perspectives on organizations each capture part of reality and are most useful together (Scott & Davis, 2007).

For our hospital, asking both questions now would mean checking whether the target fits our afternoon peak at all and replacing order time with departure time.

References

DiMaggio, P. J., & Powell, W. W. (1983). The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48(2), 147-160. https://doi.org/10.2307/2095101

Donaldson, L. (2001). The contingency theory of organizations. Sage.

Scott, W. R., & Davis, G. F. (2007). Organizations and organizing: Rational, natural, and open system perspectives. Pearson Prentice Hall.

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154