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Purpose – This chapter examines the developmental journey toward a sustainable health care system in the West of Skaraborg County in Sweden from 2008 to the present by proposing and illustrating the concept of a clinical microsystem to capture the work of a mobile team to care for elderly people with multiple diseases in its embedded context.

Design – An action research approach was adopted that entailed four researchers, one of whom was also a health care practitioner, engaging in iterative dialogues with the mobile team. This aimed at catalyzing joint learning in repeated action-reflection cycles at least three times a year over a period of 3 years. Data from patient databases were also drawn upon as additional resources for reflection.

Findings – The outcome of the initial periods of the team's work in the microsystem dramatically improved the care of these patients, significantly increasing quality of life and stabilizing their medical situation. It has also led to decreased resource utilization, not just by the team, but elsewhere in the wider health system.

Originality/value – We draw on and develop the concept of clinical microsystems to argue that such systems have a team at their core, but their work practices and patient outcomes require us to look beyond the team itself and take into account its interactions with patients and actors in the wider health care system. We also draw on the framework of Christensen, Grossman, and Hwang (2009) to propose that each microsystem has three distinct value configurations, namely shops, a chain, and a network. In terms of design, we suggest that the clinical microsystem can be seen as a parallel learning structure to that of the established health care bureaucracy.

Collegiality is the modus operandi of universities. Collegiality is central to academic freedom and scientific quality. In this way, collegiality also contributes to the good functioning of universities’ contribution to society and democracy. In this concluding paper of the special issue on collegiality, we summarize the main findings and takeaways from our collective studies. We summarize the main challenges and contestations to collegiality and to universities, but also document lines of resistance, activation, and maintenance. We depict varieties of collegiality and conclude by emphasizing that future research needs to be based on an appreciation of this variation. We argue that it is essential to incorporate such a variation-sensitive perspective into discussions on academic freedom and scientific quality and highlight themes surfaced by the different studies that remain under-explored in extant literature: institutional trust, field-level studies of collegiality, and collegiality and communication. Finally, we offer some remarks on methodological and theoretical implications of this research and conclude by summarizing our research agenda in a list of themes.

Recent changes in university systems, debates on academic freedom, and changing roles of knowledge in society all point to questions regarding how higher education and research should be governed and the role of scientists and faculty in this. Rationalizations of systems of higher education and research have been accompanied by the questioning and erosion of faculty authority and challenges to academic collegiality. In light of these developments, we see a need for a more conceptually precise discussion about what academic collegiality is, how it is practiced, how collegial forms of governance may be supported or challenged by other forms of governance, and finally, why collegial governance of higher education and research is important.

We see collegiality as an institution of self-governance that includes formal rules and structures for decision-making, normative and cognitive underpinnings of identities and purposes, and specific practices. Studies of collegiality then, need to capture structures and rules as well as identities, norms, purposes and practices. Distinguishing between vertical and horizontal collegiality, we show how they balance and support each other.

Universities are subject to mixed modes of governance related to the many tasks and missions that higher education and research is expected to fulfill. Mixed modes of governance also stem from reforms based on widely held ideals of governance and organization. We examine university reforms and challenges to collegiality through the lenses of three ideal types of governance – collegiality, bureaucracy and enterprise – and combinations thereof.

Collegiality is often discussed and analyzed as a challenged form of governance, a form of working that used to function well in universities prior to the emergence of contemporary and modern forms of governance. This seems to suggest that collegiality used to dominate, while other forms of governance are now taking over. The papers in volume 86 of this special issue support the notion of challenged collegiality, but also show that for the most part, nostalgic notions of “the good old days” are neither true nor helpful if we are to revitalize academic collegiality. After examining whether a golden age of collegiality ever existed, we discuss why collegiality matters. Exploring what are often described as limitations or “dark sides” of collegiality, we address four such “dark sides” related to slow decision-making, conflicts, parochialism, and diversity. This is followed by a discussion of how these limitations may be handled and what measures must be taken to maintain and develop collegiality. With a brief summary of the remaining papers under two headings, “Maintaining collegiality” and “Revitalizing collegiality,” we preview the rest of this volume.

Over the past few decades, university reforms in line with management and enterprise ideals have been well documented. Changes in the ideals underlying the missions of universities have led to changes in their modes of governing and organizing, which in turn drive further transformation of their missions. One set of reforms in Swedish higher education has been the dissolution of collegial bodies and procedures. At the same time, in recent years, we have witnessed an increased interest in collegiality and a reintroduction of collegial bodies and procedures. New translations of collegiality appear not only in how universities are organized, but also in other core aspects of research and higher education. We review examples of peer reviewing, research assessment, and direct recruitment of professors and ask: Can these new translations of collegiality be understood as a revitalization of collegiality, or is it – to draw a parallel with greenwashing – rather a matter of collegiality-washing?

While the university as an institution is a great success story, one hears the constant chatter of the crises in higher education usually associated with the organizational transformation of universities. Regardless of one’s normative assessment of these observations, the institutional success of the university has been accompanied by the emergence of universities as organizational actors. I reflect on how these changes could alter the university as an institution, using the Australian higher education sector as an example. In doing so, I explore how universities as organizational actors, in responding to the demands of their external environment, set in motion a series of changes that redefine highly institutionalized categories, and, in doing so, radically remake the university as an institution.

Ulla Andin received her MD in 2007 at the Faculty of Medicine at Lund University, in the Department of Geriatric Psychiatry. The title of her dissertation was Vascular Dementia, Classification and Clinical Correlates. She is a specialist in geriatrics and has been working as a senior physician at Skaraborg Hospital Group since 2008. Her focus is on elderly patients with multiple illness. Earlier in her career, she worked as a senior physician at USÖ (Universitetssjukhuset i Örebro), where she focused on patients with dementia. In addition, she has served as a supervisor for young physicians.

Reality breakdowns generate reflexivity and awareness of the constructed nature of social reality. These pivotal moments can motivate institutional inhabitants to either modify their social worlds or reaffirm the status quo. Thus, reality breakdowns are the initial points at which actors can conceive of new possibilities for institutional arrangements and initiate change processes to realize them. Studying reality breakdowns enables scholars to understand not just how institutional change occurs, but also why it does or does not do so. In this paper, we investigate how institutional inhabitants responded to a reality breakdown that occurred during our ethnography of collegial governance in a large North American university that was undergoing a strategic change initiative. Our findings suggest that there is a consequential process following reality breakdowns whereby institutional inhabitants construct the severity of these events. In our context, institutional inhabitants first attempted to restore order to their social world by reaffirming the status quo; when their efforts failed, they began to formulate alternative possibilities. Simultaneously, they engaged in a distributed sensemaking process whereby they diminished and reoriented necessary changes, ultimately inhibiting the formulation of these new possibilities. Our findings confirm reality breakdowns and institutional awareness as potential drivers of institutional change and complicate our understanding of antecedent microprocesses that may forestall the initiation of change efforts.