Framing the question Hospitals are hard organizations to change. Publicly owned and operated hospitals even more so. In many countries, both managers and staff anticipate, despite constant calls for improvements in efficiency, quality, and responsiveness, that little will be different tomorrow or next year. Similarly, politicians, seeking to outflank these intra-institutional expectations, have learned to introduce major reforms early in their term to maximize what leverage they have over public hospital managers and staff. This creates a narrow window for organizational change in public hospitals which, combined with the standard political hazards [1], still has only a relatively low probability of success, and thus further reinforces the view of hospital management and staff that ‘this too shall pass’. Conversely, while public hospitals remain broadly insulated from major policy-driven change, there continues to be rapid successful change in the practice of medicine. This can be seen in clinical treatments, diagnostic technology, in reduced lengths of stay and increased ambulatory treatment, all in spite of a shift to patients being older, more complex and with increasing amounts of chronic disease. Taken together, these conflicting trends result in most public hospital change being technical and functional rather than organizational and institutional. Even as clinical responses change relatively rapidly, departmental and institutional routines remain broadly insulated, ensuring organizational stability for many regular daily activities. This can be an important positive from the perspective of hospital staff, and, sometimes, patients, but not always for the latter if it means long waits in a traditional outpatient department or the other tedious things that patients have to do to accommodate ingrained hospital routines. In routine operating aspects, stability also can mean organizational stasis and inertia regarding clinical issues as well as larger policy and management objectives – an important negative from the perspective of health sector reform [2]. This intricate pattern of public hospitals’ internal resilience and external resistance can be observed in a variety of countries and in a range of different financial and institutional circumstances. Among the most visible examples have been the mixed success achieved over the past 20 years to eliminate unacceptably long waiting times for elective procedures in English and Swedish hospitals [3, 4]. Further examples can be observed in the slow pace of organizational and institutional change in public hospitals following major reform in the English NHS [5] and resistance to structural change in the Norwegian [6] health systems; the unsteady development of hospital level semi-autonomy in some newly built hospitals in some Spanish provinces [7], and the complexity of introducing elements of institutional self-management in Estonia [8]. Examples of similar reactions to efforts to introduce major organizational change can be found in Portugal [9] as well as in Israel [10].