The Organizational Economics of Transition

What Happens to Organizations Built for One World When the World Changes

The Rural Health Transformation Program asks approximately 4,000 rural health organizations — Critical Access Hospitals, Federally Qualified Health Centers, community behavioral health centers, tribal health programs, Rural Health Clinics — to do something that organizational theory suggests most of them cannot do: transform their operating model while continuing to deliver services under the old one.

This is not a management problem. It is a structural problem with deep roots in organizational economics, institutional theory, and the sociology of organizations. The thinkers who built these fields — Selznick, Williamson, Pfeffer, Hannan, DiMaggio, North, Ostrom — were asking a version of the same question that RHTP forces into the open: How do organizations that were shaped by their environment respond when that environment fundamentally changes?

The answer, across sixty years of research, is: most of them don’t. Not because they lack will. Because they lack the structural capacity to become something other than what their environment made them.

This document traces the intellectual traditions that explain why, and what that means for the organizations navigating the RHTP transition — and for GrantBridges, which is building the tools to measure whether the transition is working.

I. The Resource Dependence Problem

Pfeffer and Salancik (1978): The External Control of Organizations

Jeffrey Pfeffer and Gerald Salancik’s resource dependence theory begins with a deceptively simple observation: organizations survive by acquiring resources from their environment. The organization does not exist independently of that environment. It is constituted by it. Its structure, its strategies, its internal power arrangements, and its very identity are shaped by who controls the resources it needs.

The implications are profound and directly applicable to rural health:

Power follows resources. Within any organization, the departments and individuals who manage the relationship with the dominant resource provider accumulate power. In a Medicaid-dependent FQHC, the billing department, the compliance office, and the government relations function are not support services — they are the core of the organization’s survival apparatus. The clinical mission is real, but the organizational architecture is built around revenue extraction from government payers.

Organizations manage dependence, not independence. Pfeffer and Salancik showed that organizations do not seek to eliminate resource dependence. They seek to manage it — through diversification, buffering, bridging strategies, political activity, and inter-organizational alliances. An FQHC that depends on Medicaid for 60% of its revenue does not try to eliminate that dependence. It tries to stabilize it: lobbying for favorable reimbursement rates, building relationships with state Medicaid offices, joining FQHC associations that advocate collectively. The entire strategic apparatus is oriented toward maintaining the existing resource relationship, not replacing it.

Resource substitution is not neutral. When the dominant resource shifts — when Medicaid revenue is cut and RHTP grant funding is offered as a partial replacement — the organization faces a structural crisis that goes beyond budgets. The skills, relationships, power arrangements, and institutional knowledge that sustained the old resource relationship are suddenly less valuable. The skills needed for the new resource relationship — grant writing, milestone reporting, expenditure tracking, workforce pipeline management — may not exist in the organization. The people who held power under the old regime (the billing director who managed Medicaid claims) are displaced by the people needed for the new regime (the grants manager who can navigate 2 CFR 200). This is not a training problem. It is a political problem inside the organization.

The RHTP implication: Resource dependence theory predicts that organizations with the highest Medicaid dependence will have the hardest time transitioning to RHTP, not because they lack motivation but because their entire organizational architecture — staffing, power distribution, strategic orientation, external relationships — was built for a world where Medicaid revenue was the primary resource. Replacing that resource with time-limited grant funding requires not just new revenue but new organizational structure, new internal politics, and new competencies. The Readiness Survey measures whether organizations believe they are ready. Resource dependence theory explains why self-assessment may be unreliable: the organizations least prepared for the transition are the ones whose existing structure gives them the least capacity to perceive their own unpreparedness.

II. The Structural Inertia Problem

Hannan and Freeman (1984): “Structural Inertia and Organizational Change”

Michael Hannan and John Freeman’s organizational ecology introduced a Darwinian framework to organizational studies. Their core argument: organizations are subject to structural inertia — internal and external pressures that resist change — and the degree of inertia increases with organizational age, size, and environmental stability.

This is not a claim about organizational culture or leadership quality. It is a structural argument about the forces that make organizations reproducible and reliable, which are the same forces that make them resistant to transformation.

Internal sources of inertia:

Sunk costs in existing capabilities. A Critical Access Hospital that has invested decades in building a 25-bed inpatient facility, training staff for inpatient care, and developing relationships with Medicare intermediaries cannot pivot to a mobile care delivery model without abandoning investments that define its identity and operations. The RHTP vision of de-centering hospitals in favor of distributed and mobile care delivery collides directly with the physical and human capital that hospitals have accumulated under the old model.

Internal politics and power distribution. Organizational change redistributes power. The departments and individuals who thrive under the current model — inpatient nursing, facility management, traditional billing — have rational reasons to resist a transition that diminishes their role. This is not obstructionism. It is the predictable behavior of actors whose organizational position is threatened by structural change. Hannan and Freeman argued that this internal political resistance is not a bug in organizational design but a feature of organizational reliability: the same political equilibrium that makes the organization stable under normal conditions makes it resistant under transformative ones.

Information filters and bounded rationality. Herbert Simon’s concept of bounded rationality (1947, Administrative Behavior) is amplified by organizational structure. Organizations develop routines for processing information that are optimized for their current environment. A compliance office built to manage Medicaid reporting processes Medicaid-shaped information efficiently. When the information environment changes — when the relevant compliance framework shifts from Medicaid state plan requirements to 2 CFR 200 Uniform Guidance — the existing information processing routines produce errors, delays, and misinterpretations. The organization is not ignorant. It is fluent in the wrong language.

External sources of inertia:

Legitimacy and accountability. Organizations in regulated environments face what Hannan and Freeman called “legitimacy barriers to change.” An FQHC that deviates from its established model risks losing credibility with funders, regulators, patients, and community stakeholders who expect continuity. The paradox: RHTP demands transformation, but the regulatory and community environment rewards reliability. An organization that aggressively restructures to pursue RHTP priorities may lose the community trust and regulatory standing that made it eligible for RHTP in the first place.

Environmental selection, not adaptation. Hannan and Freeman’s most provocative claim: organizational populations change not because individual organizations adapt but because inert organizations fail and are replaced by new organizations better suited to the new environment. If this is correct, the RHTP transition will not primarily produce transformed existing organizations. It will produce organizational death (hospital closures, FQHC failures) and organizational birth (new entities formed to operate under the RHTP model). The policy assumption that existing organizations will transform may be selecting against the structural reality that most cannot.

The RHTP implication: Structural inertia theory predicts that the organizations with the longest histories, the most established routines, and the deepest community roots — precisely the organizations that RHTP is designed to strengthen — will be the most resistant to the transformation RHTP requires. The Compliance Burden Survey (CBS) measures the cost of compliance. Structural inertia theory explains why those costs are not merely administrative: they are the friction generated when an inert organizational structure encounters a novel compliance regime. The burden is not in the paperwork. It is in the organizational displacement required to produce the paperwork.

III. The Isomorphism Problem

DiMaggio and Powell (1983): “The Iron Cage Revisited”

Paul DiMaggio and Walter Powell asked a question that is directly visible in the rural health landscape: Why do organizations in the same field look so similar to each other? Every FQHC has a sliding fee scale. Every Critical Access Hospital has 25 or fewer beds. Every tribal health program has a P.L. 93-638 compact or contract. The structural similarity is striking, and it is not accidental.

DiMaggio and Powell identified three mechanisms of institutional isomorphism — three forces that push organizations in the same field toward structural similarity:

Coercive isomorphism results from political pressure and regulatory mandates. FQHCs look alike because the Health Resources and Services Administration (HRSA) requires them to meet the same 19 program requirements: governing boards with 51% patient majority, sliding fee schedules, specific service delivery requirements. CAHs look alike because the Medicare Conditions of Participation and the 25-bed limit define their structural boundaries. Organizations in regulated fields do not choose their organizational form. The regulatory environment imposes it.

Mimetic isomorphism results from uncertainty. When organizations face ambiguous environments, they model themselves on organizations they perceive as successful. This is visible in the early RHTP implementation: states that received awards early (Kansas, South Dakota, Washington) become templates for states that follow. Organizations that successfully navigate the application process become models for organizations that have not yet applied. The structural form propagates not because it is optimal but because it is observable and imitable under conditions of uncertainty.

Normative isomorphism results from professionalization. The graduate programs that train healthcare administrators, the professional associations (NACHC for FQHCs, NRHA for rural health), the consulting firms that advise on compliance and strategy — all propagate shared norms about how a rural health organization should be structured, what it should prioritize, and how it should respond to policy changes. When RHTP arrives, every organization’s response is filtered through the same professional norms, the same consultant recommendations, and the same association guidance. The range of possible organizational responses is narrowed before any individual organization makes a decision.

The iron cage applied to RHTP: DiMaggio and Powell’s insight is that isomorphism is simultaneously a source of legitimacy and a constraint on adaptation. Organizations that conform to institutional expectations gain legitimacy — they are more likely to receive funding, pass audits, and retain community trust. But conformity narrows the range of adaptive responses available when the environment changes. If every FQHC responds to RHTP by hiring a grants manager, creating a compliance committee, and contracting with the same two or three consulting firms, the field achieves isomorphic compliance without organizational transformation. The form changes. The substance may not.

This is measurable. The Application Complexity Index (ACI) implicitly measures coercive isomorphism — the degree to which the application process forces organizational conformity. The Workforce Pipeline Report measures whether normative isomorphism (shared professional training models) produces genuine workforce development or merely credentialed similarity. The Braided Funding Map measures whether organizations can break free of isomorphic single-stream dependence.

IV. The Institutional Environment

Douglass North (1990): Institutions, Institutional Change and Economic Performance

Douglass North’s institutional economics distinguishes between institutions (the rules of the game) and organizations (the players). This distinction is fundamental to understanding the RHTP transition, because the policy debate conflates them constantly.

Institutions are constraints. They include formal rules (statutes, regulations, contracts) and informal constraints (norms, conventions, codes of conduct). The institutional environment for rural healthcare includes: the Social Security Act, Medicare Conditions of Participation, Medicaid state plans, 2 CFR 200 Uniform Guidance, HRSA program requirements, state licensing laws, accreditation standards, professional licensing requirements, and the informal norms of rural healthcare practice (community obligation, mission orientation, acceptance of below-market compensation).

Organizations are shaped by institutions. North’s core claim: the institutional environment determines what kinds of organizations are viable, what strategies they pursue, and what skills they develop. Rural health organizations did not choose to become compliance-heavy, Medicaid-dependent, community-governed entities. The institutional environment selected for those characteristics. Organizations that developed them survived. Organizations that didn’t, closed.

Institutional change and organizational lag. North identified a critical asymmetry: institutions can change faster than the organizations they shaped. A statute can be enacted in a legislative session. The organizations that must comply with it — organizations that were shaped by decades of prior institutional rules — cannot restructure in a legislative session. The One Big Beautiful Bill Act changed the institutional environment in 2025. The organizations operating within that environment were shaped by institutional rules accumulated since 1946 (Hill-Burton), 1965 (Medicare/Medicaid), 1989 (FQHC program), and 2010 (ACA expansion). The lag between institutional change and organizational adaptation is not a failure of management. It is a structural feature of how institutions and organizations co-evolve.

Path dependence. North’s concept of path dependence explains why the organizational response to RHTP is constrained by prior institutional history. An FQHC that spent 20 years building its organizational capabilities around Medicaid managed care — negotiating MCO contracts, managing utilization review, building referral networks within MCO provider panels — cannot redeploy those capabilities toward RHTP grant management. The capabilities are path-dependent: they were developed in response to a specific institutional environment and are not transferable to a different one. The organization must build new capabilities from scratch while maintaining the old ones (because Medicaid hasn’t disappeared overnight — the cuts phase in over a decade).

The RHTP implication: North’s framework predicts that the transition will produce a period of institutional disequilibrium — where the new rules (RHTP) coexist with the old rules (Medicaid, Medicare, HRSA requirements) and organizations must simultaneously comply with both. This dual compliance burden is not a design flaw in RHTP. It is the predictable consequence of institutional change in a field where prior institutions have not been abolished, only reduced. The CBS measures this dual burden directly. North’s theory explains why it is structural and will not be resolved by better training or improved technology.

V. The Commons Problem

Elinor Ostrom (1990): Governing the Commons

Elinor Ostrom’s work on common-pool resource governance offers a framework that the RHTP policy conversation has largely missed: rural healthcare infrastructure as a commons.

A commons is a shared resource system where one user’s consumption affects availability for others, but exclusion is difficult or undesirable. Rural healthcare infrastructure — the hospital, the clinic, the ambulance service, the behavioral health provider — exhibits commons characteristics. The entire community depends on it. Its financial viability depends on broad participation (a sufficient payer mix). Its collapse harms everyone, including those who did not directly use it. And its governance requires collective action that the market does not naturally provide.

Ostrom’s eight design principles for successful commons governance, derived from empirical study of communities that sustainably managed shared resources, map onto the RHTP challenge with uncomfortable precision:

1. Clearly defined boundaries. Who is in the community? Who has claims on the healthcare commons? RHTP defines this through eligible entity types and geographic service areas, but the boundaries are administratively imposed, not community-determined.

2. Proportional equivalence between benefits and costs. Those who benefit from the commons should bear proportional costs. In rural healthcare, the cost of maintaining infrastructure falls disproportionately on the providers (through below-cost reimbursement) and local governments (through subsidies and tax exemptions), while the benefits accrue to the entire community.

3. Collective-choice arrangements. Users should participate in rule-making. FQHC governing boards with patient majority requirements are an attempt at this principle. RHTP’s state-administered, federally-defined grant structure is not. The organizations managing the commons have limited voice in the rules governing it.

4. Monitoring. Ostrom found that successful commons require monitoring by parties accountable to the users. RHTP monitoring is performed by state administering agencies and federal auditors accountable to the funding source, not to the community. GrantBridges’ data products represent a different kind of monitoring — independent, public-facing, accountable to the field rather than to the funder.

5. Graduated sanctions. Successful commons impose proportional penalties for rule violations. The RHTP compliance framework, with its audit triggers, disallowed costs, and clawback provisions, imposes sanctions that may not be proportional to the capacity of small rural organizations. The CBS measures whether sanctions are graduated or binary.

6. Conflict-resolution mechanisms. Ostrom found that durable commons have accessible, low-cost dispute resolution. The federal grants dispute resolution process (administrative appeals, DAB review) is neither accessible nor low-cost for a 15-person Rural Health Clinic.

7. Minimal recognition of rights to organize. Communities must be permitted to create their own governance institutions. RHTP constrains organizational forms through eligible entity definitions, spending categories, and compliance requirements. The question is whether these constraints enable or inhibit community self-governance of their healthcare commons.

8. Nested enterprises. Complex commons require governance at multiple nested levels. RHTP has this structure (federal → state → sub-grantee → community) but the nesting is hierarchical and administrative, not polycentric in Ostrom’s sense. Decisions flow downward. Accountability flows upward. Community governance is at the bottom of both flows.

The RHTP implication: Ostrom’s framework suggests that the long-term sustainability of rural healthcare infrastructure depends less on the size of the initial investment (the $50 billion) than on the governance arrangements that manage the commons after the investment. If RHTP builds infrastructure but does not create governance arrangements that allow communities to manage that infrastructure collectively, the investment produces assets without stewards. The Sustainability Survey (M-SUST) measures organizational readiness for post-RHTP operation. Ostrom’s framework suggests it should also measure community governance capacity — the ability of the broader community, not just the funded organization, to sustain the healthcare commons.

VI. Transaction Costs and Organizational Boundaries

Oliver Williamson (1985): The Economic Institutions of Capitalism

Oliver Williamson’s transaction cost economics asks why organizations exist at all — why some activities are organized within firms rather than purchased through markets. His answer — transaction costs, asset specificity, bounded rationality, and opportunism — illuminates a dimension of the RHTP transition that policy discussions typically ignore: the question of organizational boundaries.

Asset specificity and the make-or-buy decision. Rural health organizations face a recurring decision: which capabilities should they build internally, and which should they purchase from external providers? Under the Medicaid model, many organizations externalized complex functions: revenue cycle management to billing companies, IT to managed service providers, compliance to consulting firms. This was rational because the transaction costs of managing these relationships were lower than the costs of building internal capacity for functions that required specialized expertise.

RHTP changes the calculus. The grant requires workforce development, infrastructure investment, technology adoption, and compliance capabilities that may need to be internalized — because the knowledge required is organization-specific (high asset specificity) and the consequences of opportunistic behavior by external vendors are high (a compliance failure affects the organization, not the vendor). But internalizing these capabilities requires organizational growth at precisely the moment when revenue uncertainty is highest.

Bounded rationality and contract incompleteness. Williamson built on Simon’s bounded rationality to explain why contracts are inherently incomplete — parties cannot anticipate all future contingencies. The RHTP grant agreement is a contract between the federal government, the state, and the sub-grantee. It is necessarily incomplete: it cannot specify what should happen when a sub-grantee faces simultaneous Medicaid revenue loss, workforce shortages, and RHTP compliance obligations that exceed its administrative capacity. The compliance framework attempts to fill these gaps with rules, but rules designed for complete contracts create friction when applied to incomplete ones.

The RHTP implication: Williamson’s framework predicts that the organizations best positioned for the RHTP transition are those that can efficiently reorganize their boundaries — bringing in-house the capabilities that RHTP requires while maintaining market relationships for functions that remain standardized. The organizations worst positioned are those locked into long-term vendor relationships (multi-year EHR contracts, outsourced billing arrangements) that were optimized for the old model and cannot be restructured without significant transaction costs. The Application Complexity Index implicitly measures whether the application process recognizes these boundary decisions or assumes organizational forms that don’t match reality.

VII. The Theory of Institutional Work

Lawrence and Suddaby (2006): Bridging Structure and Agency

The theories above share a structural orientation: they explain how environments shape organizations and constrain change. Thomas Lawrence and Roy Suddaby’s concept of institutional work offers a counterpoint: individuals and organizations actively create, maintain, and disrupt institutions. They are not merely acted upon.

This matters for the RHTP transition because structural determinism — the prediction that most organizations cannot transform — is not the whole story. Some organizations will transform. Some communities will successfully manage the transition. The question is what enables agency within structural constraint.

Lawrence and Suddaby identified three types of institutional work:

Creating institutions. Some actors build new rules, norms, and governance arrangements. In the RHTP context, the state administering agencies that design implementation frameworks, the tribal health organizations that negotiate 638 compact terms, and the intermediary organizations that develop sub-grantee support systems are all engaged in institutional creation. They are not just complying with RHTP. They are building the local institutional environment within which RHTP operates.

Maintaining institutions. Other actors work to preserve existing arrangements. The advocacy organizations (NACHC, NRHA, NCAI) that lobby for continued Medicaid funding alongside RHTP, the state Medicaid offices that resist enrollment restrictions, and the community health workers who maintain relationships that predate any grant program are all engaged in institutional maintenance. This is not resistance to change. It is the preservation of institutional capacity that the new regime has not yet replaced.

Disrupting institutions. Still others work to undermine existing arrangements. The political actors who designed the simultaneous Medicaid cut and RHTP creation are engaged in institutional disruption at the national level. At the organizational level, leaders who deliberately restructure their organizations to pursue the RHTP model — closing inpatient beds to fund mobile care, redirecting compliance staff from Medicaid to grants management, renegotiating vendor contracts to build internal capacity — are engaged in institutional disruption at the organizational level.

The RHTP implication: The transition will not be determined solely by structural forces. It will be shaped by the institutional work of specific actors — state agencies, tribal organizations, intermediaries, organizational leaders, and community advocates — who actively build, maintain, or disrupt the institutional environment. GrantBridges’ role in this framework is as a producer of institutional knowledge: the data products, the published research, and the compliance tools create shared information that enables institutional work by others. The State Implementation Confidence Index measures institutional creation capacity at the state level. The Tribal Access Scorecard measures the institutional environment for organizations operating under sovereign governance frameworks.

VIII. Where the Operating Lens Layers Connect

The capabilitygraph’s operating lens identifies four layers: Flow (operations research), People (human factors), Workforce, and Incentives (public finance). The organizational economics of transition is where these layers intersect, because organizational transformation is simultaneously:

An operations problem (Flow). The organization must redesign workflows, reporting systems, and service delivery models while maintaining current operations. This is the dual-operating-system challenge that John Kotter described — running the existing organization while building the new one. Queueing theory, throughput analysis, and critical path methods from the operations research discipline apply directly to the question of how an organization sequences the transition without service disruption.

A human factors problem (People). The individuals within the organization face cognitive load, role ambiguity, decision degradation under uncertainty, and the fatigue of operating in two regimes simultaneously. The bounded rationality that Simon identified and that Williamson applied to contracts also applies to the human decision-makers navigating the transition. They are being asked to make consequential decisions — about organizational structure, resource allocation, strategic direction — under conditions of radical uncertainty, with incomplete information, and with personal stakes (their own jobs, their community’s healthcare access) that make rational analysis difficult.

A workforce problem. The RHTP workforce provisions — recruitment incentives, training partnerships, rural service commitments — assume that workforce can be developed through investment. Organizational ecology suggests that workforce development is constrained by the organizational environment: workers are attracted to, retained by, and productive within organizations that have the structural capacity to support them. Recruiting a nurse practitioner to a rural clinic that is simultaneously managing Medicaid revenue loss, RHTP compliance, and organizational restructuring is a different proposition than recruiting to a stable, well-funded practice. The Workforce Pipeline Report measures pipeline throughput. Organizational economics explains why throughput is a function of organizational stability, not just recruitment spending.

An incentives problem (Public Finance). The payment model evolution — from fee-for-service through value-based care to population-based funding — is not just a reimbursement question. It is an organizational design question. Each payment model implies a different organizational form. Fee-for-service rewards volume, which implies a production-oriented organization. Value-based care rewards outcomes, which implies a coordination-oriented organization. Population-based funding rewards community health, which implies a governance-oriented organization. The RHTP transition asks organizations to move along this spectrum while the payment models they actually receive revenue from are mixed and changing.

The organizational economics of transition is the connective tissue. It explains why the layers cannot be addressed independently — why a workforce strategy that ignores organizational inertia will fail, why a compliance system that ignores resource dependence will burden, why a payment model that ignores isomorphism will produce conformity without transformation.

IX. What This Means for Measurement

Every GrantBridges data product is implicitly measuring a dimension of organizational capacity for transition. The intellectual traditions in this document make those measurements legible as theoretical constructs, not just survey responses:

This is not retrospective rationalization. These theoretical frameworks predict specific patterns in the data that the instruments are designed to collect. If resource dependence theory is correct, the Readiness Survey will show systematic overconfidence among the most Medicaid-dependent organizations. If structural inertia theory is correct, the Workforce Pipeline Report will show that older, larger organizations have lower retention rates despite higher recruitment spending. If Ostrom’s commons framework is correct, the Sustainability Survey will show that organizations with stronger community governance score higher on post-RHTP viability regardless of RHTP award size.

The data products don’t just describe the transition. They test the theories that explain it.

X. The Stakes

The organizational economics of transition is not an academic exercise. It is the analytical framework for the most consequential question in American rural health policy: Can time-limited public investment produce permanent organizational transformation in communities where the structural economics of healthcare delivery have not changed?

The political project assumes yes. The organizational theory reviewed here suggests the conditions are far more constrained than the policy acknowledges. Neither answer is predetermined. The answer will emerge — in the manner that emergent systems produce outcomes from local rules — from the decisions of thousands of organizations, each navigating its own resource dependencies, structural constraints, institutional pressures, and internal politics.

GrantBridges exists to measure the emergence. The data products are the instruments. The organizational economics of transition is the theoretical framework that makes the measurements interpretable. Without it, the data describes. With it, the data explains.

Intellectual Debts

This document draws on the following primary works:

• Selznick, P. (1957). Leadership in Administration: A Sociological Interpretation. The concept of organizational character and institutional identity.
• Simon, H. (1947). Administrative Behavior. Bounded rationality as the foundation of organizational decision-making.
• Pfeffer, J. & Salancik, G. (1978). The External Control of Organizations: A Resource Dependence Perspective. How resource environments shape organizational structure and strategy.
• Williamson, O. (1985). The Economic Institutions of Capitalism. Transaction cost economics and the theory of organizational boundaries.
• DiMaggio, P. & Powell, W. (1983). “The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields.” American Sociological Review 48(2).
• Hannan, M. & Freeman, J. (1984). “Structural Inertia and Organizational Change.” American Sociological Review 49(2).
• North, D. (1990). Institutions, Institutional Change and Economic Performance. Institutional economics and path dependence.
• Ostrom, E. (1990). Governing the Commons: The Evolution of Institutions for Collective Action. Design principles for sustainable commons governance.
• Lawrence, T. & Suddaby, R. (2006). “Institutions and Institutional Work.” In Clegg et al., Sage Handbook of Organization Studies.
• Kotter, J. (2014). Accelerate: Building Strategic Agility for a Faster-Moving World. The dual operating system model for organizational transformation.

Applied healthcare contexts that informed this analysis:

• Starr, P. (1982). The Social Transformation of American Medicine. The political and economic history of American healthcare institutions.
• Scott, W.R., Ruef, M., Mendel, P., & Caronna, C. (2000). Institutional Change and Healthcare Organizations. How institutional pressures shape healthcare organizational fields.
• Begun, J., Zimmerman, B., & Dooley, K. (2003). “Health Care Organizations as Complex Adaptive Systems.” In Mick & Wyttenbach, Advances in Health Care Organization Theory.
• Alexander, J., Weiner, B., Metzger, M., et al. (2003). “Sustainability of Collaborative Capacity in Community Health Partnerships.” Medical Care Research and Review 60(4).