Agency at the Managerial Interface: Public Sector Reform as Institutional Work

This article draws on recent developments in institutional theory to better understand the managerial efforts implicated in the implementation of government-led reforms in public sector services. Based on a longitudinal study of a massive reform effort aimed at transforming the province of Quebec's publicly-funded healthcare system, the article applies the notion of institutional work to understand how managers responsible for newly formed healthcare organizations defined and carried out their individual missions while simultaneously clarifying and operationalizing the government's reform mandate. We identify and describe the properties of four types of work implicated in this process and suggest that structural work, conceptual work, and operational work need to be underpinned by relational work to offer chances for successful policy reform. By showing the specific processes whereby top-down reform initiatives are taken up by managers and hybridized with existing institutionalized forms and practices, this article helps us better understand both the importance of managerial agency in enacting reform, and the dynamics that lead to policy slippage in complex reform contexts.