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Few large institutions have changed as fully and dramatically as the U.S. healthcare system since World War II. Compared to the 1930s, healthcare now incorporates a variety of new technologies, service-delivery arrangements, financing mechanisms, and underlying sets of organizing principles.

This book examines the transformations that have occurred in medical care systems in the San Francisco Bay area since 1945. The authors describe these changes in detail and relate them to both the sociodemographic trends in the Bay Area and to shifts in regulatory systems and policy environments at local, state, and national levels. But this is more than a social history; the authors employ a variety of theoretical perspectives—including strategic management, population ecology, and institutional theory—to examine five types of healthcare organizations through quantitative data analysis and illustrative case studies.

Providing a thorough account of changes for one of the nation's leading metropolitan areas in health service innovation, this book is a landmark in the theory of organizations and in the history of healthcare systems.

We love the local. From the cherries we buy, to the grocer who sells them, to the school where our child unpacks them for lunch, we express resurgent faith in decentralizing the institutions and businesses that arrange our daily lives. But the fact is that huge, bureaucratic organizations often still shape the character of our jobs, schools, the groceries where we shop, and even the hospitals we entrust with our lives. So how, exactly, can we work small, when everything around us is so big, so global and standardized? In Organizing Locally, Bruce Fuller shows us, taking stock of America’s rekindled commitment to localism across an illuminating range of sectors, unearthing the crucial values and practices of decentralized firms that work.
           
Fuller first untangles the economic and cultural currents that have eroded the efficacy of—and our trust in—large institutions over the past half century. From there we meet intrepid leaders who have been doing things differently. Traveling from a charter school in San Francisco to a veterans service network in Iowa, from a Pennsylvania health-care firm to the Manhattan branch of a Swedish bank, he explores how creative managers have turned local staff loose to craft inventive practices, untethered from central rules and plain-vanilla routines. By holding their successes and failures up to the same analytical light, he vividly reveals the key cornerstones of social organization on which motivating and effective decentralization depends. Ultimately, he brings order and evidence to the often strident debates about who has the power—and on what scale—to structure how we work and live locally.

Written for managers, policy makers, and reform activists, Organizing Locally details the profound decentering of work and life inside firms, unfolding across postindustrial societies. Its fresh theoretical framework explains resurging faith in decentralized organizations and the ingredients that deliver vibrant meaning and efficacy for residents inside. Ultimately, it is a synthesizing study, a courageous and radical new way of conceiving of American vitality, creativity, and ambition. 

 

Americans at the end of the twentieth century worried that managed care had fundamentally transformed the character of medicine. In The Medical Delivery Business, Barbara Bridgman Perkins uses examples drawn from maternal and infant care to argue that the business approach in medicine is not a new development. Health care reformers throughout the century looked to industrial, corporate, and commercial enterprises as models for the institutions, specialties, and technological strategies that defined modern medicine.

In the case of perinatal care, the business model emphasized specialized over primary care, encouraged the use of surgical and technological procedures, and unnecessarily turned childbirth into an intensive care situation. Active management techniques, for example, encouraged obstetricians to accelerate labor with oxytocin to augment their productivity. Despite the achievements of the childbirth and women’s health movement in the 1970s, aggressive medical intervention has remained the birth experience for millions of American women (and their babies) every year.

The Medical Delivery Business challenges the conventional view that a dose of the market is good for medicine. While Perkins is sympathetic to the goals of progressive and feminist reformers, she questions whether their strategies will succeed in making medicine more equitable and effective. She argues that the medical care system itself needs to be fundamentally "re-formed," and the reforms must be based on democracy, caring, and social justice as well as economics.