Managing in a complex world: Accounting and governance choices in hospitals

The healthcare sector has experienced significant challenges stemming from market demands, competition, and regulation, which pressures hospitals to change their operations and decision-making. In contrast to mainstream business enterprises, decisions to change accounting systems or to improve hospital governance occur in a complex institutional environment with multiple stakeholders. The hospital setting thus provides both opportunities and challenges for researchers. This overview paper uses recent studies in the field to illustrate how hospital choices are driven by the institutional environment in which hospitals operate. Incorporating the richness of this institutional environment into research may help researchers to make better predictions about: 1) why certain accounting systems or types of governance models are implemented or maintained; and 2) why certain intended outcomes are not always realised. The paper also sets out a research agenda that further capitalises on the impact of multiple institutional stakeholders within hospital decision-making structures. This area of research is relevant to academics, policy-makers, and the healthcare profession at large. It can offer valuable insights on the types of governance structures and accounting systems that are likely to be more effective and can help shape healthcare policy.