Rethinking organizational culture in intersectoral coordination: the perspective of boundary work.

PURPOSE: The purpose of this paper is to rethink the concept of organizational culture as something that emerges bottom-up by using the sociological concepts of boundary object and boundary work as an analytical lens and to show how this approach can help understand and facilitate intersectoral coordination. DESIGN/METHODOLOGY/APPROACH: We used observations and qualitative interviews to develop "deep" knowledge about processes of intersectoral coordination. The study draws on a conceptual framework of "boundary work" and "boundary objects" to show how a bottom-up perspective on organizational culture can produce better understanding of and pave the way for intersectoral coordination. We use a case of health professionals engaged in two Danish intersectoral programs developing and providing health promotion services for women with gestational diabetes mellitus (GDM). FINDINGS: The study showed how boundary work revolves around negotiations on how to define, understand and act on the diagnosis of GDM. This diagnosis has the characteristics of a "boundary object", being more loosely structured in general terms, but strongly structured in local settings. Boundary objects help connect different professionals and facilitate coordination. The analysis showed how the introduction of time and the concept of "lifelong health promotion" helped to transgress existing organizational and professional boundaries. RESEARCH LIMITATIONS/IMPLICATIONS: The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination and collaboration. While the theoretical implications will be general applicable when studying organizational culture, the implications for practice are sensitive to context and the processes we have described as the outcomes of boundary work are generated from cases that were most likely to provide deep insight into our research topic. PRACTICAL IMPLICATIONS: For practice this can build bridges between organizational and professional boundaries. ORIGINALITY/VALUE: The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination. This may build bridges between organizational and professional boundaries in practice settings.

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting.

BACKGROUND: Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC). OBJECTIVES: To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC. METHODS: Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary. RESULTS: The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive. CONCLUSION: The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

Task shifting from general practitioners to other health professionals could increase treatment capacity in out-of-hours primary care.Task shifting occurs for care to patients with less urgent and less complex health issues.The long-term implications of task shifting in out-of-hours primary care should be investigated.

Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention.

BACKGROUND: Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being. METHODS: A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices. DISCUSSION: The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being. TRIAL REGISTRATION: ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.

Tackling social inequalities in health: Assessing contexts for implementing integrated health access for people with severe mental illness.

Social inequalities in health are a complex problem that often emerge at the interfaces between different sectors, such as health and social care, and the corresponding transitions between different provider organisations. Vulnerable people are typically in greater need of accessing different sectors of the health system and therefore often experience lack of coherence in their treatment pathway. We aimed to examine the contexts of health systems that influence initiatives concerned with integrated health access. We used the theory of Organizational Fields to study the contexts for implementing Flexible Assertive Community Treatment (FACT) in Central Denmark Region and three municipalities in the region. We collected 33 documents and conducted six qualitative interviews with professionals involved in FACT to understand the contexts of implementing integrated health access. We found that contexts for implementing FACT are highly complex, as they are divided between health and social care (horizontal complexity) and between national and the sub-national levels of the region and the municipalities (vertical complexity). This leads to conflicting demands on implementation. Local contexts of collaboration may offer a lever to handle these demands, but these are likely to vary. Analysis of how complex health system contexts influence implementation is important to understand how changes might become sustainable and help to tackle social inequalities in health.

Post-COVID health policy responses to healthcare workforce capacities: A comparative analysis of health system resilience in six European countries.

A cross countries in Europe, health policy is seeking to adapt to the post-pandemic 'permacrisis', where high demands on the healthcare workforce and shortages continue and combine with climate change, and war. The success of these efforts depends on the capacities of the healthcare workforce. This study aims to compare health policy responses to strengthen the capacities of the healthcare workforce and to explore the underpinning dynamics between health systems, policy actors and health policies. The study draws on a qualitative, comparative analysis of Austria, the Czech Republic, Denmark, Germany, Italy and the Netherlands. The findings suggest that policy responses at the national level focused on hospitals and absorptive capacities, while policy responses at local/regional levels also included general practice and adaptive capacities. There were only few examples of policies directed at transformative capacities. The underling dynamics were shaped by health systems, where individual parts are closely connected, by embeddedness in specific service delivery and areas, and by power dynamics. In conclusion, sub-national health policy responses emerge as key to effective responses to the post-pandemic permacrisis, where health professions are central policy actors. Sub-national health policy responses build on existing power relations, but also have the potential to transcend these power relations.

Comparative health policy goes qualitative: Broadening the focus of research after COVID-19.

The COVID-19 pandemic has pushed health policy frontstage and exposed the stark differences in government capacities to respond to the crisis. This has created new demands for comparative heath policy to support knowledge creation on a large scale. However, comparative health policy has not necessarily been well prepared; studies have focused on health systems and used typologies together with descriptive, quantitative methods. This makes it difficult to capture the multi-level nature of health policy, the diverse actors involved and the many societal facets of governance performance. We argue for broadening the perspective to include health policy as a bottom-up process with diverse interests. This calls for expanding the methodology of comparative health policy by also using approaches that make greater use of explorative, qualitative research. We introduce possible developmental pathways to illustrate what this may look like. The Pan-European Commission shows how to broaden the definition of comparative health policy, notably as transnational and planetary. The gender analysis matrix illustrates how comparative health policy can strengthen its assessment of performance by focussing on gender equity. The street-level bureaucrat framework highlights how analysing frontline work can help conduct small-scale bottom-up comparisons of health policy. Together, these developmental pathways demonstrate the potential to broaden comparative health policy towards greater responsiveness to the societal performance of governments, such as social inequalities created by the COVID-19 pandemic. This also opens opportunities for strengthening the global outlook of comparative health policy.

Who cares?-The unrecognised contribution of homecare nurses to care trajectories.

BACKGROUND: Organisation of patients' trajectories is a critical element of nursing practice. However, nursing practice is mainly expressed in terms of direct patient care, while the practices through which care is organised have received little attention, are poorly acknowledged and lack formal recognition. AIM: To examine the management of care trajectories as provided by homecare nurses. DESIGN: We conducted focus group interviews with 29 Danish homecare nurses. The analysis drew on the evidence based and theoretically informed framework care trajectory management. Care trajectory management is conceptualised as comprising of three organisational components: (1) Trajectory awareness, (2) Trajectory working knowledge and (3) Trajectory articulation. FINDINGS: The organising work of homecare nursing is both complex and unpredictable requiring advanced organisational, collaborative and clinical competences to secure concerted actions in alignment with the needs of the individual patient. Without having any formal obligation homecare nurses took on the responsibility for the coordination of the different activities of the professional actors, and for securing concerted actions. Care trajectory management as provided by homecare nurses reflected a high degree of commitment for patients and illustrated that this type of organising work was driven by the values of the humanistic ethos of nursing. CONCLUSION: The study highlights the strength of the invisible and ongoing organising work of homecare nurses. Care trajectory management in homecare reflects the moral foundation of nursing. Consequently, the professional logic of nursing reflected as direct patient care alone is too narrow. We need to acknowledge the organising work of patients' trajectories as a core task equal to direct patient care. Our study highlights the need for articulating the organising work of homecare nurses and for presenting problematic organisational structures to policymakers and managers. If not, the important organisational work of homecare nurses is at the risk of remaining invisible.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries.

BACKGROUND: The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries. AIMS: We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities. MATERIALS AND METHODS: We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information. RESULTS AND DISCUSSION: Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities. CONCLUSION: This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

The contribution of professions to the governance of integrated care: Towards a conceptual framework based on case studies from Denmark.

OBJECTIVE: Good governance of integrated care is key to better health care, but we know little about how professions can help make this happen. Our aim is to introduce a conceptual framework to analyse how professions contribute to the governance of integrated care, and to apply the framework to a secondary analysis of selected case studies from Denmark. METHODS: We developed a framework, which identified the what, how and why of the contribution professions make to the governance of integrated care. We included five qualitative Danish studies, using coordination as an indicator of integrated care. We adopted a thematic approach in our analysis, combining deductive and inductive elements. RESULTS: Health professions engage in highly diverse activities, which fall into closely connected clusters of more formal or more informal coordination. Professions apply many different adaptive mechanisms at different levels to fit coordination into local contexts. Professions are driven by interlocking rationales, where a common focus on patients connects organizational and professional concerns. CONCLUSIONS: Our analytical framework emerges as a useful tool for analysis. The contribution of professions to the governance of integrated care needs greater attention in health policy implementation as it can promote more effective governance of integrated care.

Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems.

This article is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. The study aims to strengthen health workforce preparedness, protection and ultimately resilience during a pandemic. We argue for a health system approach and introduce a tool for rapid comparative assessment based on integrated multi-level governance. We draw on secondary sources and expert information, including material from Denmark, Germany, Portugal and Romania. The results reveal similar developments across countries: action has been taken to improve physical protection, digitalization and prioritization of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing. Developments were more diverse in relation to occupational and organizational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strongest in Demark and weak in Portugal and Romania. Major governance gaps exist in relation to education and health integration, surveillance, social and mental health support programmes, gendered issues of health workforce capacity and integration of migrant healthcare workers (HCW). There is a need to step up efforts and make health systems more accountable to the needs of HCW during global public health emergencies.

Conditions for successful interprofessional collaboration in integrated care - Lessons from a primary care setting in Denmark.

INTRODUCTION: Increasing demand for interprofessional collaboration in health care settings has led to a greater focus on how conditions influence the success of interprofessional collaboration, but little is known about the magnitude of the interactions between different conditions. This paper aims to examine the relationships of intervention conditions and context conditions at the professional and organisational level and examine how they influence the staff's perceived success of the interprofessional collaboration. METHODS: The study was conducted as a multilevel cross-sectional survey in March of 2019 in the second largest municipality in Denmark, Aarhus. The study population was all frontline-staff members and managers in nursing homes, home care units and health care units. The final sample consisted of 498 staff members and 27 managers. Confirmatory path analysis was used to analyse the data. RESULTS: The results indicate that context conditions greatly influence intervention conditions at the professional and organisational level and that the professional and organisational levels moderately co-variate. Professional level context conditions have the biggest influence on staff's perceived success, partly because its influence is confounded by intervention conditions. CONCLUSION: Practice and research in health care settings should re-focus their attention from a broad understanding of context as unchangeable and inconsequential, to understanding context as an important condition type for interprofessional collaboration that needs to be further understood and researched.

Relational coordination in inter-organizational settings. How does lack of proximity affect coordination between hospital-based and community-based healthcare providers?

Coordination among healthcare providers in intra- and inter-organizational networks is critical for the provision of seamless and efficient healthcare. Relational Coordination (RC) represents a type of coordination that enables network participants to manage interdependencies and has consistently been found to improve quality and efficiency of patient care. The majority of RC studies focuses on intra-organizational settings, while less is known about inter-organizational settings. This pilot study examined RC in relation to a collaboration between a hospital-based geriatric team and a community-based acute care team. The study focused especially on how structural challenges due to lack of technological, geographical and organizational proximity between the healthcare providers affected RC, drawing on literature on inter-organizational collaboration. We adopted a qualitative case design to gain an in-depth understanding of barriers and facilitators of interprofessional RC. Data included seven qualitative interviews with healthcare professionals and managers across the two provider teams and 16 hours of participant observations. Findings suggested that core tasks were coordinated through strong RC, while RC in non-core tasks were systematically hindered by structural challenges of the inter-organizational setting. Findings also indicated that RC in core tasks was partly dependent on formal coordination mechanisms to overcome frictions in inter-organizational structures.

Personalised medicine and the state: A political discourse analysis.

The last decade has seen a range of health policy initiatives relating to personalised medicine. There is an emerging body of studies that demonstrates the continued importance of states in the development of personalised medicine. This paper contributes to this literature by focusing on how political discourses construct the role of states in personalised medicine. Based on a case study of the introduction of a national programme in Denmark, the analysis identifies specific discursive mechanisms in this construction. The material consists of documents from key national stakeholders, media coverage and interviews with experts at the national level. The analysis found three types of discursive mechanisms. Firstly, mechanisms can relate to problem definitions, and these were concerned with a number of salient problems of health services. Secondly, mechanisms can relate to underlying assumptions, and these were about the possibility of engineering healthcare improvement through data and by extension personalised medicine. Thirdly, mechanisms can relate to discursive effects, and here the state emerged as a highly influential governor. These mechanisms are likely to be highly relevant for other countries, but future research needs to test this. Health policy practitioners and health administrators thus need to invest effort into influencing political discourses around personalised medicines, in addition to the formulation of policies itself.

Fine for non-attendance in public hospitals in Denmark: A survey of non-attenders' reasons and attitudes.

OBJECTIVE: To investigate non-attending patients' reasons for non-attendance and their general and specific attitudes towards a non-attendance fine. DATA SOURCES: Non-attenders at two hospital departments participating in a trial of fine for non-attendance from May 2015 to January 2017. DESIGN: A quantitative questionnaire study was conducted among non-attenders. DATA COLLECTION: Non-attending patients in the intervention group were invited to complete the questionnaire. The response rate was 39% and the total number of respondents was 71 individuals. PRINCIPAL FINDINGS: The main reason for non-attendance was technical challenges with the digital appointment and with cancelation. The main part of the respondents was generally positive towards a fine for non-attendance. However, approximately the half had a negative attitude towards the actual fine issued. CONCLUSIONS: Technical challenges with appointments and cancelation should get special attention when addressing non-attendance. Danish non-attending patients are primarily positive towards the general principle of issuing a fine for non-attendance. However, a significant proportion of the generally positive, reported a negative specific attitude to the specific fine issued to them. This, however, did not affect their general attitude.

Implementing Integrated Community-Based Primary Healthcare: Applying the iCoach-Approach to Case Selection to Denmark.

BACKGROUND: The iCoach approach to case selection focuses on innovative models of community-based primary healthcare (CBPHC) and their contexts. The aim of this study was to assess the possibilities and limitations of the approach based on Denmark, which differs in significant ways from the jurisdictions initially included. THEORY AND METHODS: Case study research suggests the approach is an interesting attempt to standardise case selection based on literal replication. The study reviewed the national grey literature and interviewed key informants at national and local levels. RESULTS: Applying the approach to Denmark required redefining selection criteria related to collaboration and context to capture its specific institutional and policy context. Selecting cases at the organisational level also required assessing how the system level contexts compared to those of the initial three jurisdictions included in iCoach. DISCUSSION: The iCoach approach allows collecting broadly comparable cases of innovative models of CBPHC across jurisdictions. However, the analysis of underlying conditions of implementing innovative models requires a more interactive approach to case selection. CONCLUSION: Researchers need to be clearer about the specific purpose of the case selection. This is also highly relevant for practitioners to ensure that insights are applicable in specific local and national contexts.

Sustaining an intervention for physical health promotion in community mental health services: A multisite case study.

There is a growing body of literature on sustainability, but its definition and the factors that affect it are not well understood. This paper focuses on the sustainment of health promotion interventions in community mental health organisations, where the institutional context has been found to play an important role. Normalisation Process Theory (NPT) was used to characterise the extent of sustainment of health promotion interventions and to identify important factors that influence it. The study builds on a previously reported qualitative multiple case design focusing on four Danish community mental health organisations. We aimed to include cases (provider organisations) with varied political-administrative contexts that were expected to impact sustainment. Data included 27 semistructured interviews with managers and frontline staff. The analysis adopted a thematic approach combining within-case and cross-case analysis. One important factor contributing to sustainment was the high degree of coherence generated during and after implementation. Perceptions of meaningfulness and formal tools for external accountability such as municipal activity plans also stimulated the cognitive participation of management and staff in sustaining the intervention. On the practical level of collective action, working with health promotion in a continuous way was particularly supported by two formal tools: internal health policies and municipal activity plans. Sustainment was further aided by reflexive monitoring based on ongoing informal assessments, supplemented by information required for status reports to the municipality on individual users and information from the annual individual user health checks. Future studies should adapt NPT to a broader range of cases to assess more thoroughly its contribution to the literature on sustainment. Future interventions need to pay closer attention to securing continuous and active local management support as well as to political-administrative contexts as potential external drivers of sustainment.

Healthcare governance, professions and populism: Is there a relationship? An explorative comparison of five European countries.

A new wave of support for populist parties and movements represents a serious threat to universal healthcare coverage in traditional liberal democracies and beyond. This article aims to contribute empirical material on the relationships between healthcare governance, professions and populism. It applies an explanatory cross-country comparative approach and uses mixed methods, including micro-level data garnered from international comparative databases and documents. Denmark, England, Germany, Italy and Turkey have been selected for comparison, reflecting different types of healthcare systems and populist movements. The results reveal variety in the ways populist discourses impact in healthcare. Abundant economic resources, network-based governance, high levels of trust in healthcare providers and doctors participating as insiders in the policy process seem to work as a bulwark against populist attacks on healthcare and professional expertise. On the other hand, poorly resourced NHS systems with doctors as outsiders in the policy process and major NPM reforms together with low to medium levels of trust in healthcare providers may be fertile ground for populist discourse to flourish. Our explanatory data provide hints of correlations, which may inform further studies to investigate causality. Yet the research highlights that healthcare governance and professions matter, and brings into view capacity for counteracting populist attacks on universal healthcare and professional knowledge.

Primary care workforce development in Europe: An overview of health system responses and stakeholder views.

Better primary care has become a key strategy for reforming health systems to respond effectively to increases in non-communicable diseases and changing population needs, yet the primary care workforce has received very little attention. This article aligns primary care policy and workforce development in European countries. The aim is to provide a comparative overview of the governance of workforce innovation and the views of the main stakeholders. Cross-country comparisons and an explorative case study design are applied. We combine material from different European projects to analyse health system responses to changing primary care workforce needs, transformations in the general practitioner workforce and patient views on workforce changes. The results reveal a lack of alignment between primary care reform policies and workforce policies and high variation in the governance of primary care workforce innovation. Transformations in the general practitioner workforce only partly follow changing population needs; countries vary considerably in supporting and achieving the goals of integration and community orientation. Yet patients who have experienced task shifting in their care express overall positive views on new models. In conclusion, synthesising available evidence from different projects contributes new knowledge on policy levers and reveals an urgent need for health system leadership in developing an integrated people-centred primary care workforce.

A call for action to establish a research agenda for building a future health workforce in Europe.

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

Beyond Activity Based Funding. An experiment in Denmark.

Over past decades Activity Based Funding has been an attractive tool for hospital funding and governance, but there has been growing frustration especially with its unintended effects. There are numerous examples of alternative models, but there is little in-depth knowledge about how these models came about. The aim of our study was to analyse how the discourse of Activity Based Funding was successfully challenged. This contributes insights into how international/national debates are translated into concrete alternative models through specific discursive mechanisms. The analysis used a discursive policy approach and was based on a case study from Denmark ('New Governance'). The data consisted of project and policy documents as well as qualitative interviews with regional and national experts. The analysis identified four discursive mechanisms: the problem definitions underlying 'New Governance' were clear and simple; the underlying assumptions both accepted and challenged the premises of Activity Based Funding; the alternative of 'New Governance' was defined in rather broad terms; and it was produced, disseminated and defended as part of interweaving processes regionally but also nationally. Our study showed that new models of hospital funding and governance need to be carefully engineered and that they draw on a mix of governance logics. Future research needs to study more examples from a broad range of institutional contexts and points in time.