Energy Research & Social Science 44 (2018) 385–398

Contents lists available at ScienceDirect

Energy Research & Social Science

journal homepage: www.elsevier.com/locate/erss

Original research article

Beyond technocracy: Forms of rationality and uncertainty in organizational T

behaviour and energy efficiency decision making in Canada
John Maiorano
University of Toronto, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: Through a social science approach rooted in grounded theory, this research paper provides a form of an un-
Energy efficiency certainty theory in organizations, exploring how alternate forms of rationality and approaches to dealing with
Uncertainty uncertainty result in variation in energy efficiency related actions and outcomes. Through data analysis,
Organizational behaviour structural conditions are identified, frames for considering energy efficiency are uncovered, and two approaches
Decision making
for dealing with uncertainty are interpreted. Hospitals that approach uncertainty by 'Demanding Certainty' make
Risk
use of one of two frames: 'Temporal Silos' or' Alternate priorities'. These hospitals communicate by presenting,
selling and confirming, resulting in risk avoiding organizations where individuals absorb associated risks, and
long-term energy efficiency implementation stalls. Hospitals that approach uncertainty by 'Managing
Complexity' envision energy efficiency as complementary to patient care and driving long-term resiliency. These
hospitals communicate through negotiation and collaboration, expanding thinking beyond short term budgetary
intervals, driving resiliency and bridging operational silos. Organizations, and not individuals, absorb risks as-
sociated with energy efficiency, and implementation of initiatives occur over longer time horizons.

1. Introduction According to a neoclassical perspective, failures to adopt profitable energy

According to the Intergovernmental Panel on Climate Change [1],
limiting the impacts of climate change will require substantial and sus-
tained reductions of greenhouse gas emissions. While 30–40% of all
primary energy use occurs in buildings [2], accounting for nearly one
quarter of total greenhouse gas pollution in the Province of Ontario [3],
hospitals account for a proportionally higher amount as they operate
around the clock and have extra requirements for clean air, disease
control, imaging equipment and waste management [4]. In 2015, hos-
pital greenhouse gas emissions in Ontario were 0.73 megatonnes (MT)
[5], equal to 4.7% of the 15.5 MT of emissions in the Ontario non-re-
sidential buildings sector [57] and nearly 1/200th, of the overall 166 MT
of greenhouse gas emissions in Ontario [57]. While investment in energy
efficiency can lead to significant cost savings, and is often regarded as the
fastest and most cost-effective method to achieve global greenhouse gas
emission targets [6] and promotes environmental protection and better
public health [7], there is evidence that Ontario hospitals fail to invest in
energy efficiency even though it is profitable to do so [8]. This phe-
nomenon is referred to as the “energy efficiency gap” [9].
Research on energy efficiency in buildings has been widespread,
however it has been dominated by technocratic, engineering and eco-
nomic based approaches. Behavioural, organizational and institutional
perspectives have also been applied to explore energy behavour (see [10]).
efficiency projects are due to market failures, imperfections or market
barriers [9,11]. This approach has been criticized for its inability to ex-
plain multiple actor behavior [12,13] and for the systematic constraints
and biases that influence individual decision-making [58]. The beha-
vioural perspective suggests individuals don’t behave completely ration-
ally, rather they exhibit bounded rationality (Simon, 1955). Constraints on
time and cognition, including the ability to process information, limit
decision making power. The behavioural perspective draws on two broad
approaches: behavioural economics and psychology-based theories. Sorrell
et al. [14] are a key contributor in extending understanding of this per-
spective, introducing information costs, opportunism, bounded rationality,
transaction costs, biases, errors and decision heuristics as hindering in-
dividual decision making regarding energy efficiency implementation.
DeCanio [15] provided impetus to scholars exploring the energy
efficiency gap to go beyond individual decision making, as he showed
statistically that data from the US Environmental Protection Agency’s
voluntary pollution prevention programs could not be explained by
standard economic models. He found that both economic and organi-
zational factors accounted for the variation in observed lighting up-
grade investment returns. As an economist, he argued that individuals
were self-interested and could be incentivized, however that collective
behavior within organizations resulted in behavior and outcome that
were often suboptimal. Some explanations he provided included the

E-mail address: John.Maiorano@utoronto.ca.

https://doi.org/10.1016/j.erss.2018.05.007
Received 1 November 2017; Received in revised form 9 May 2018; Accepted 10 May 2018
2214-6296/ © 2018 Elsevier Ltd. All rights reserved.
J. Maiorano
interplay of individual motivations, rules and conventions governing
interactions, hierarchies, and rules of procedures. He implored in-
vestigation of how organizational characteristics and inter-organiza-
tional dynamics impact decision-making within organizations, and to
provide more comprehensive theories of behavior of firms pertaining to
energy efficiency practices. In summarizing an organizational per-
spective to energy efficiency, Crittenden [10] outlines the following
organizational-level factors in the literature that limit the uptake of
profitable energy efficiency projects, including: organizational structure
[12], degree of collaboration across organizations [16,17], visibility of
energy use [59], routines and capability (Cooremans, 2011; 60].
While the behavioural and organizational perspectives progress un-
derstanding of energy behavior and decision making, they continue to be
based on binary notions of rationality. Friedland and Alford [61] con-
ceptualize rationality as a relative concept, which depends upon where
individuals and organizations are located, or locate themselves, within a
number of cultural or institutional orders. This causes actors to act ra-
tionally according to the belief system to which they ascribe – perhaps the
market order, perhaps the family order, the religious order or the com-
munity order. Biggart and Lutzenhiser [18] explain that social norms and
community structure can impact who is responsible for decision making,
and the bases on which they are made. In critiquing classical perspectives
of self-interested individual behavior, Dobbin ([62] p.2), in a book laying
out the key features of economic sociology, endorses this view explaining
that the rationalized lenses through which individuals view the world are
largely shaped by social institutions, as much through regulation and
policy as norms provided by professional associations or educational in-
stitutions, and beliefs and values socially constructed and promulgated
through culture and religion. So, whereas economic approaches ignore the
influence of social context, sociological approaches counter that in-
dividuals behave according to scripts, schemas, conventions, or logics,
tied to their roles, which are both influenced and influence cultural
practices and shared expectations [63]. As such, there is a need to broaden
the perspectives, to incorporate a social science approach capturing so-
cietal influences on organizational structures, organizational culture and
decision making surrounding the energy efficiency gap [19–21].
Non-rationalist or social science approaches have been dominated by
positivist traditions and researchers have called for more constructivist
approaches [22] to understand how energy use and energy choices are
made in organizations and multi-organization systems and why parti-
cular outcomes come about. This includes improving understanding of
how resource allocation, training, culture, power dynamics and multiple
forms of rationality shape energy use in organizations [23].
Recently, Andrews and Johnson [24] provide their own summary of
the literature to date on energy behavior in organizations and state, rather
simply, that research on energy behavior within an organizational context
is underwhelming. They call for greater consideration of this topic at three
levels of analysis: individuals in organizational contexts, the behavior and
social characteristics of organizations themselves and the institutional
structures, rules, and networks that influence their activity. They argue
that each of these levels provide rich and dynamic sources of research on
mechanisms that can drive or constrain energy efficiency. Under-devel-
oped topics include sector-specific studies on barriers to energy innovation
and integrated studies exploring the determinants of organizational energy
behavior at the individual, organizational and institutional levels.
This study extends understandings of energy efficiency by making use
of a social scientist approach, using qualitative research methods, to
explore and extend understandings of energy behavior within an orga-
nizational and institutional context. Through the use of a grounded
theory methodological approach theoretical insights surrounding energy
efficiency practices in Ontario hospitals are developed. While the
grounded theory approach does not rely on prior theories, the in-
vestigation was approached as an organizational scientist, exploring “the
complexities of the relationships between the units at different levels of
analysis that comprise organizations” ([25], p.74–75). This includes
386
Energy Research & Social Science 44 (2018) 385–398
understanding how organizational settings and organizational members
mutually influence one another, how broader structure influences action,
and how action influences structure. In this manner, the study did not
exclusively explore context, nor did it exclusively study behavior, instead
it studied “behavior in context” ([25], p. 82). This was achieved by
making use of an inductive approach, through an interpretivist and
constructivist epistemological and ontological orientation to explore the
dynamics of energy efficiency practices in Ontario hospitals.
The following three research questions guide the methodology:
1 What structural conditions surround the implementation of energy
efficiency practices in Ontario hospitals?
2 How do organizational responses to structural conditions sur-
rounding energy efficiency differ?
3 Why are energy efficiency practices in Ontario hospitals hetero-
geneous? That is why are some hospitals more successful at reducing
energy use and associated greenhouse emissions than others?
2. Energy conservation practices in Ontario hospitals
Investigating the energy management practices of Ontario’s hospi-
tals offers an ideal setting to pursue investigation. While hospitals in
Ontario are located in diverse communities, from very urban to very
rural, and can range in size from very small to very large, they are
influenced by similar normative and cultural-cognitive pressures and
are accountable to the same federal and provincial regulations that
determine their funding and guide their non-profit structure.
For most hospitals in Ontario, there are no regulatory requirements on
hospitals to reduce energy use or GHG emissions. In 2013, through Ontario
Regulation 397/11, the first mandatory reporting requirements were in-
troduced. All public agencies in Ontario are required to report their annual
energy use and GHG emissions for each of their sites, to the Ministry of
Energy, beginning with the calendar year 2011. In addition, public agen-
cies were required to develop five-year energy conservation and demand
management (CDM) plans by July 1, 2014, made publicly available on
their websites and in hard copy. The CDM plans provide information on the
agency’s energy consumption and GHG emissions, along with a plan for
how they will conserve energy. Plans must be updated every five years.
Reviewing 108 CDM plans available on hospital websites, 18 hospi-
tals proposed at least one million dollars’ worth of energy conservation
measures with payback periods between 3 to 16 years, while 25 hospitals
proposed total measures of up to one million dollars. Alternatively, 65
hospitals proposed no energy conservation measures at all despite this
being a required element of the plan [26]. Twelve of these hospitals
submitted five year plans with limited to no discussion of conservation-
related aspirations. The Green Hospital Scorecard provides a high-level
snapshot of energy and environmental performance with participation
from 55 hospitals, or approximately 40% of all Ontario hospitals. Case
studies in the scorecard report suggest some of these hospitals are placing
an importance on energy and resource conservation and implementing
energy saving retrofits [27]. While for other hospitals, lack of capital and
staff resources have hindered conservation efforts [64,8].
The box plot diagrams below summarize three metrics of Ontario
hospital sites: their 2015 Energy Intensity, 2015 GHG Emissions and the
percentage change in their Energy Intensity from 2011 to 2015.
Changes in energy intensity vary, with an average increase of 1.9% for
all hospital sites from 2015 to 2011, and a median change of −6.1%.
The interquartile range is 30.3% with the central 50% of hospital sites
between −17.8% and 12.5%. The 2015 average energy intensity for all
sites is 14.4 eWh/HDD/sqft, with an interquartile range of 7.7. The
interquartile range of GHG emissions is 2754 tonnes, with the central
50% of hospital sites emitting between 305 and 3059 tonnes of CO2e.
There is a large outlier, Victoria Hospital of the London Health Sciences
Centre which has an on-site cogeneration-based power plant.
J. Maiorano
2.1. Box plots: 2015 energy intensity, 2015 GHG emissions and % change
in energy intensity from 2011 vs. 2015 in all Ontario hospital sites
As of January 1, 2017, a cap and trade system was introduced in
Ontario, which created a stronger financial incentive for large hospitals
to become more energy efficient. Large emitters, or those emitting over
25,000 tonnes of direct CO2e annually, are mandatory participants in
the system. This includes only two facilities at Ontario’s 144 hospitals.
Eleven facilities from ten Ontario hospitals that emit over
10,000 tonnes annually but are not large emitters can decide to become
voluntary participants. Only one of these eleven hospital facilities has
decided not to become a voluntary participant [28], All non-participant
hospitals will be subject to pass through cap and trade fees from natural
gas utility providers [29]. Note, the box plot for GHG emissions above
does not include the second large emitting facility based on cap and
trade system public reporting, as that hospital did not report GHG
emissions associated with their co-generation plants in their broader
public sector reporting.
Finally, the table below outlines regional differences amongst
Ontario hospitals, based on their assignment to local health integration
networks (LHINs). Centrally located hospitals, those located in the
surrounding Toronto area, are both the largest and most energy in-
tensive. These hospitals, in urban centers, with central access to energy
services, have produced CDM plans outlining the largest average in-
vestments in conservation per site. Hospitals located in Northern
Ontario, an expansive land territory which is more remote and ex-
perience colder temperatures, have the smallest hospitals on average,
and are the least energy intensive, when accounting for heating degree
days. Northern hospitals also have the second highest proposed in-
vestment in conservation projects, despite their small size, and the
highest proportion of sites with detailed conservation investments
proposed in their CDM plans, despite this being very low, at 22%.
2.2. Regional differences
Ontario Region Sites Energy Intensity (eWh/ GHG (tonnes
HDD/ft2) CO2e)
South West 48 12.73 2293
Central West 49 15.95 2169
Central 66 17.12 3619
East 56 14.26 2504
North 60 11.74 1523
Average per site N/A 14.43 2462
Professional norms related to energy efficiency practices in Ontario
are disseminated through professional associations, electricity system
operators and NGOs with provincial reach. This includes CHES-ON, the
OHA, the IESO and the Canadian Coalition for Green Health Care.
387
Energy Research & Social Science 44 (2018) 385–398
Conferences are administered at least annually sharing best practices
through peer presentations, conference information booths and green
energy awards ceremonies. Conferences are well attended by hospital
members, consultants, academics, energy providers and NGOs. While
practitioners representing smaller hospitals or those located in more
remote locations may be less likely to attend in person due to staffing or
travel, the conferences have been providing access through recorded
webinars. Rural hospitals have networked with other local hospitals to
create local professional knowledge-sharing hubs.
3. Methodology
The research makes use of grounded theory to shape data collection,
analysis and theory construction. The research does not attempt to
make use of quantitative research methods as “quantitative logic applies
preconceived categories or codes to the data, which differs from the logic of
grounded theory coding.” ([65] p.46). The grounded theory method de-
veloped by Glaser and Strauss [30] has proven powerful for offering
qualitative researchers an iterative inductive process to generate social
theory through comparative analysis of data obtained through social
research. A grounded theorist’s attempt is to generate new theories and
understandings through contextual analysis of actions and events, and
to produce generalizable theoretical statements that transcend specific
times and places [65].
Constructivist grounded theory is the most recent reform of
grounded theory, aligning with an interpretivist and constructivist
epistemology. This version of grounded theory challenges early pre-
mises that theory emerges from the data, proposing rather that it is the
researcher that constructs categories, not aiming for context-free par-
simonious explanations and generalizations, but rather for an inter-
pretive understanding of phenomenon accounting for context [31]. In
accounting for a reality that is multiple, processual and constructed, the
research process emerges from interaction between the researcher and
the researched. As such, data are co-constructed, and require the con-
sideration of each participant’s positionality, prior knowledge and
theoretical preconceptions. In this manner, data collection and coding
also require consideration of who it is that is being researched in terms
of how the interview participant understands their position, their or-
ganization and how they see and interpret their world. This allows for
theory development that takes implicit meanings and views of experi-
ences as constructions of reality [31] “preserving the complexity of
social life” ([32], p. 397).
3.1. Data collection, open sampling and analysis
Interviewing as a method of data collection is often criticized for
being artificial when compared to observations in natural settings;
Size beds CDM % of Sites with Investments proposed
(ft2) Investment in CDM
245,832 74 179,197 13%
218,898 97 54,961 12%
440,392 153 636,796 17%
303,303 120 118,730 13%
178,078 66 262,238 22%
284,091 104 271,348 17%
however, it is a common approach under grounded theory. Unlike other
methodologies, such as ethnography, grounded theory demands more
direct control over data collection and analysis. Open-ended, in-depth
interviewing allows for flexibility and control over data collection
through “directed conversation” [66], with the researcher permitted to
J. Maiorano
explore more deeply aspects of a participant’s experiences based on
earlier and ongoing data comparison and analysis.
Hospital employees in a number of roles were interviewed. This
includes senior managers in operations, clinical services, finance, ca-
pital planning and corporate services, and departmental staff and
managers working in facilities and services, engineering and environ-
mental services. The sample of hospitals interviewed was representative
of the population, including small, medium and large hospitals in
geographically dispersed rural and urban areas throughout the pro-
vince. The intent of the data collection was to achieve depth in theo-
retical sampling to maximize variations in experiences and descriptions
by accounting for all types of hospitals, in all types of settings. As 53%
of hospitals have less than 100 beds, a stratified random samples of
hospitals was created, with 25 hospitals with less than 100 beds ran-
domly selected in the first strata and 25 hospitals with more than 100
beds selected in the second strata.
The first phase of interviews were intended to gain multiple per-
spectives from a rich theoretical sample. Interviews were open-ended to
explore processes, participant rationales and meanings associated with
energy conservation practices. The first four interviews asked partici-
pants to describe energy conservation practices in their setting, in-
cluding their experiences, concerns, challenges and methods to over-
come them. Interviews were recorded and transcribed, and initial
coding was used to study words, lines, statements and incidents. Labels
were used as essence-capturing, and to categorize, summarize or in-
terpret words, phrases and responses. In instances where the partici-
pant’s meaning behind salient excerpts was to be preserved, in-vivo
coding was used. Memos were written as analytic ideas began to
emerge. From the memos, further questions emerged surrounding cer-
tain thoughts, phrases or conceptions. Emerging codes were constantly
compared to earlier codes to generate understandings and insights.
After this first phase, lack of resources and prioritization of other
initiatives was a common theme stated plainly by participants, but
implicit concepts related to risk aversion and resistance to borrowing
funds implored new questions and probes. Nodes emerged related to
uncertainty, budget pressures and lack of priority. How hospitals in-
terpreted and reacted to uncertainty related to energy efficiency mea-
sures, both in an individual and organizational context was further
explored through the design of additional open-ended questions and
probes.
Additional interviews were scheduled with directors and vice-pre-
sidents of finance, capital planning and operations exploring feelings on
energy use, borrowing funds, prioritizing energy efficiency, and per-
spectives on leadership of energy efficiency in their hospital. Implicit
meanings related to responses to uncertainty, lack of control and issues
surrounding trust were interpreted. As data saturation was not yet
reached, further interviews were arranged to clarify concepts, augment
meaning and refine understandings. Additional interviews were ar-
ranged with finance, operations and facility representatives to drive an
understanding of the constraining qualities of budgetary processes and
to explore how this contributes to temporal framing, and responding to
uncertainty.
To complete axial and theoretical coding, all data were transferred
to Nvivo, as connecting categories became burdensome without the use
of data organizing software. Matrix cross classifications were used to
understand the frequency of codes along certain case attributes, such as
the frequency of certain categories relating to upper or lower man-
agement, or to directors of finance versus operations, while being
careful to not force relationships(see [33]).
To spur identification of relationships between context and process
within the data, a tool, or organizing scheme, developed by Corbin and
Strauss [34] referred to as the “paradigm” was used as an initial ap-
proach to theorize and connect categories identified in the data. This
paradigm suggests consideration of categories as denoting either: a
388
Energy Research & Social Science 44 (2018) 385–398
circumstance or structural condition, an action or a response to con-
ditions or circumstances, or a consequence/outcome (what happens as
a result of the actions or responses). The attempt of this analysis was not
to oversimplify phenomena, or to make it fit a pre-defined scheme but
rather, to provide a launching point for theoretical coding.
In total, the interview data consisted of 17 voluntary interviews.
The participants included four directors/vice presidents of finance,
capital planning and/or corporate services, six directors, vice presidents
or managers of operations, clinical or auxiliary services and seven
managers or team members in facilities and services or engineering.
There was equal representation of smaller and larger hospitals.
A second source of data was sought to confirm categories and to va-
lidate theoretical coding. A roundtable discussion organized by Buildings
Magazine, entitled Energy Efficiency in Hospital Buildings explored ap-
proaches to drive forward energy performance in healthcare facilities in
Ontario. The roundtable of twelve participants included five hospital
employees working as senior director of operations, manager of facilities
and services, and in engineering and sustainability teams. Consultants,
utility providers, and equipment vendors were also included. A transcript
of the roundtable discussion was coded to further refine categories and
themes. As a member of the roundtable discussion, I used the platform to
explore themes from the interviews, including perspectives on budgetary
pressures, lack of control and risk aversion.
Maps were developed as theoretical connections emerged.
Conceptualizations and causal relationships were tested and confirmed
by constantly going back to the interviews completed with the 17
employees of 14 hospitals and to the codes and categories generated by
the roundtable discussion. Further interviews and data collection were
not deemed necessary as theoretical saturation was reached: themes
and categories were redundant and there was substantial data to sup-
port theoretical validation.
4. Findings
The findings in the following sections are organized by the orga-
nizing scheme used to connect themes and categories, and to generate
theory for variation in energy efficiency outcomes in Ontario hospitals.
Section four below describes the structural conditions, including the
circumstances or situations that impact energy efficiency decision
making in Ontario hospitals. Section five describes the core category,
‘Dealing with Uncertainty’, and its contribution to theory development
in this paper. Section six outlines the actions, or the strategic responses
to energy efficiency related issues within the structural conditions un-
covered. This includes the frameworks that individuals within this
context use to make sense of energy efficiency. Finally, section seven
describes the resulting outcomes stemming from the actions and stra-
tegic response presented in section six. This includes hospitals acting
differently depending on how they both frame energy efficiency and
respond to uncertainty in their environment. The findings in each of
these sections are distilled in Table 4.
4.1. Structural conditions
By analyzing participant responses, codes were generated and ca-
tegories defined, revealing the organizational context, or structural
conditions, surrounding energy efficiency practices in Ontario hospi-
tals. In response to the first research question, the following three
structural conditions allowed for deeper interpretation of individual
action and organizational practice surrounding energy efficiency prac-
tices within Ontario hospitals:
1 Patient Care
2 Budgetary Pressures
3 Issues of Control
J. Maiorano
4.1.1. Patient care
Throughout all levels of management it is clear from the participant
responses that the primary mission of a hospital is to serve its patients.
Administrators and employees see themselves as stewards of public
health, incorporating issues of patient care in their decision making. As
such, energy conservation practices are seen through the lens of patient
care. Framing energy conservation in these terms, some administrators
see energy efficiency as an opportunity to improve resiliency, safety,
reliability and patient comfort. For others, energy efficiency measures
are seen as a disturbance, compromising spaces, creating operational
complexity, and using up capital, impacting the delivery of patient care.
Interestingly, attitudes of stewardship and patient care extend to
perspectives on other hospitals; they are united as stewards of health in
the province. While hospitals are clear they operate individually, they
understand they are inextricably connected to the hospitals that sur-
round them. Hospitals share a mutual connection through the financial
pressures and adversity they confront, and while they expect an equal
and fair system, they are not outright opposed to older or less efficient
hospitals getting a greater share of infrastructure funding. By improving
efficiency in the most energy consuming hospitals in the short term,
more funding will be available to all hospitals in the long term. In this
manner, individual hospitals in Ontario see their success in delivering
patient care, as being dependent on the success of all.
4.1.2. Budgetary pressures
Hospitals in Canada are public institutions, and for the majority of
their services do not charge patients or collect revenue directly from
patients. The bulk of their funding is the responsibility of the provincial
level of government, as per the Public Hospitals Act. Health care is the
Government of Ontario’s single largest government expenditure, with
38.7% or $51.8 billion of the 2016 Provincial budget allocated to health
care [35]. Funding is distributed from the province to the Ontario
Ministry of Health and Long Term Care, who then apportions to four-
teen local health integration networks (LHIN) equipped with local and
expert knowledge of the funding requirements of hospitals in their
jurisdiction.
Through negotiated hospital service accountability agreements
(HSSA), Local Health Integration Networks (LHINs) allocate and dis-
tribute funding to hospitals in their regional network. In order to better
align hospital revenue with expenses, Ontario is increasing the amount
of hospital funding that is considered variable pay, based on the
number of patients treated each year [36]. In 2016, this amounted to
approximately 30% of hospital funding, up from 6% in 2012. The
majority of funding continues to be based on lump-sum type payments,
which estimates health care expenses based on demographics and the
type of care each hospital provides ([36,37]). Annual funding increases
or decreases to hospitals are at the discretion of the LHINs, with little
input from hospitals.
The Ministry of Health and Long-term Care (MOHLTC) require
LHINs to both plan and achieve their own balanced budget, and oblige
health service providers who receive LHIN funding to do the same
([38,39]). As such, individual hospitals are required to run a balanced
budget, where total revenues are greater than or equal to total expenses
every fiscal year. If a hospital does not balance their budget, the HSSA
requires the development of a deficit reduction plan, in consultation
with their LHIN. If an agreement cannot be reached, the MOHLTC may
become involved, replacing hospital management, followed by the ap-
pointment of a supervisor with the power to act as the Board and
Management. This has occurred in at least four hospitals from 2008 to
2013 [40].
Data analysis provided evidence that senior management consider
the balanced budget requirement not a soft target, but a legal mandate.
While patient care is considered the central mission of each hospital,
interview participants suggest the goal for hospitals each year is to
balance its budget and not get into a deficit. Lack of resources spurred
on by stagnant funding growth, escalating expenses, and the pressure to
389
Energy Research & Social Science 44 (2018) 385–398
balance each year has left many hospitals in Ontario feeling financially
constrained, while pressured to increase service delivery with little
funding remaining for energy efficiency measures.
4.1.3. Issues of control
In some hospitals, senior management feel pressured by their in-
ability to control a number of factors related to balancing their oper-
ating budget. One interview participant stated, “We are not the masters
of the revenue … and we don’t necessarily have full control over all our
escalation costs”. Incoming government funding for the upcoming year is
generally beyond individual hospital control, and may not increase
from the year before, despite rising costs. Disclosure of funding can be
untimely, and impede their ability to plan infrastructure or other types
of long term investments.
Beyond government funding, Ontario hospitals have limited rev-
enue options available to them. To prevent a ‘two-tier’ system from
taking hold, hospitals face rules against charging patients for services
beyond what is provincially prescribed.
Hospitals are able to source extra revenue through ancillary ser-
vices, such as parking and cafeteria, or through other governmental
funding sources, such as veteran’s health care or workplace accidents,
or by sourcing donations from charitable individuals, organizations or
through grants. While these additional revenue sources are not a high
proportion of total revenues, for some hospitals, these additional rev-
enue sources can make the difference towards balancing their budget.
On the expense side, hospitals feel a lack of control over a number of
sources of their costs. This includes: salary increases which are centrally
negotiated, the number of patients treated, weather conditions and
their impact on energy use, infrastructure maintenance and repair, and
the capricious energy behavior of individual users and departments.
One interview participant describes the pressures she feels in balancing
revenues with expenses, while attempting to invest in energy efficiency,
as a catch 22 situation; commonly understood to imply a difficult cir-
cumstance where there is no escape because of mutually conflicting or
dependent conditions.
“It’s a catch 22 situation… we have to budget for 0% [increase in an-
nual funding] from the ministry … but all of our costs go up, purchasing,
unions and salary increases … it is a double edged sword and you want
to get ahead and see an roi [return on investment] when you are
putting moneys into energy efficiency, but the cost up front for hospitals is
huge… and we have somewhat of a plan in place, but it is trying to
maintain that plan… we are constantly scraping.”
In summary, hospitals provide a rich and revealing space to explore
energy efficiency practices within an organizational context. The set-
ting is one driven by stewardship for the public, but with financial
pressures, and feelings of lack of control. From this stems an environ-
ment with limited room for taking on financial risk – or limited room to
make a mistake, especially a financial one that impedes patient care.
This can create a very low risk climate, especially towards innovation.
So how do hospitals operate in this environment? How do they make
sense of their environment, of their practices and of their responsi-
bilities towards becoming more energy efficient in a financially con-
strained environment? Why do some hospitals undertake efficiency
measures more readily, while in others energy efficiency investment
stalls?
5. Theoretical development: dealing with uncertainty
Grounded theory is a method not aimed solely at description, or
interpreting how respondents ascribe meaning, but rather it “must offer
a conceptually abstract explanation for a latent pattern of behavior (an
issue or concern) in the social setting under study” ([41], p. 272).
Corbin and Strauss [34] prescribe an approach for integrating data to
form conceptual theory through the identification of a central, or core
category that all other concepts and categories coded in the data relate
J. Maiorano Energy Research & Social Science 44 (2018) 385–398

to. The core category is the category that has the greatest explanatory

"We're just in the midst of sort of a facilities transformation project where we're

department. So it's going to be really under one umbrella. To make sure that we
are arguing our capital planning we are cognizant and inclusive of the facilities
management team, so that we are building for the future and building for their

resources and so on. And I think it's a simple thing to do. I don't know why, but

forward, from a sustainability and managing budget perspective going forward. I

we were always working in two separate departments with two different leaders.
And I think it's important that those two groups align. Because you can build for
the future to help the maintenance department to better manage things going
sustainability. And that's going to help them manage their budgets and their
actually aligning the capital planning development and the building services
relevance, linking other categories together with analytic power. Glaser
& Holton outline that the criteria for establishing the core category are
that: “… it is central, relating to as many other categories and their prop-
erties as possible and accounting for a large portion of the variation in a
pattern of behavior. The core variable reoccurs frequently in the data and
comes to be seen as a stable pattern that is more and more related to other
variables. It relates meaningfully and easily with other categories” ([42],
p.15). Analysis of the data led to the interpretation of a core category
which linked coded categories, contributing to theorization and ana-

Budgetary Pressures & Patient Care

lytic power. This core category was, ‘Dealing with Uncertainty’.

say finance is coming along however."

Energy management, by its nature, is a complex process pervaded
with multiple uncertainties. Uncertainties mentioned by research par-
ticipants include those that impact energy supply and demand, retrofit
implementation, technological efficacy, and risks associated with re-

Managing Complexity
lying on external professionals. Those uncertainties impacting energy
demand included weather conditions, patient and staff behavior, and
misuse of new technologies. Those impacting energy supply included in
house skills and expertise, operator management of complex equipment
and misuse of energy data. Uncertainty associated with successful im-
plementation of new technology and equipment included technical

f)
risks, disturbances, and equipment failure. Uncertainty was also evident
in the extent that hospital administrators trusted energy service com-

a chance it wouldn’t succeed. Then it would cost the organization money, you

They want to make sure there are guarantees out there, because when you do
“I wouldn’t take on a project unless I knew it was going to be successful, but I
wouldn’t do something that was risky. I wouldn’t take on a project if there was

anything in a hospital, people really have an ownership of the hospital. 'At my

"Forking out money before you get returns making financial people nervous.
panies and external consultants to honestly and efficiency manage

hospital', so everytime we make a change we are often questioned by the

population and can be comfortable and proud of the choices we made"
projects. The perception of these uncertainties may cause decision
making surrounding energy efficiency investment to stall in some or-
ganizations, depending on how they deal with this uncertainty.
Explanatory power for differences in energy efficiency practices was

know money that should be going towards patient care.”

found to be associated with differences in the ways hospitals deal with
uncertainty. One approach to dealing with uncertainty interpreted from
the data, resulting in various forms of action and outcome, was termed
“Demanding Certainty”. Under the Demanding Certainty approach,
pressured by the structural conditions of budgetary constraints, loss of
control and a mission driven by patient care and public stewardship,
hospital senior management deals with uncertainty by framing energy
efficiency through two frames that will be outlined in detail in the next
section below: Temporal Silos and Alternate Priorities. This framing
fosters an approach that absolves leadership, stalls co-ordination be-
tween departments, externalizes risks to individuals and teams, and
Patient care

results in a self-interested, risk avoiding culture where energy efficiency

projects stall, or are implemented slowly and incrementally, focused on
short payback wins. Table 1 provides select participant responses which
illustrate how structural conditions impact how some hospitals deal
d)

e)

with uncertainty surrounding energy efficiency. The first two columns

a large piece of equipment. And, absolutely they said, we are not purchasing it,

the early years in order to reap longer term benefits, but it is harder for us to do
unless you can show us what your operational budget is going to be to run that

“If something has a 5 year payback if you are a private business you can make
“When I was sitting at the capital table last, they were talking about purchasing

a business case to do that - but you tolerate some deficits or profit reductions in

“Its not that they don`t want to do it, its just that, as I said, the budget in the

percent, chop, chop, chop, chop. You would think that would be an incentive
piece of equipment for the next five years. Because we're not increasing your

under Demanding Certainty, use terms which suggest sources of un-

time period from when they started the design to when it actually came out,

looking at how does this affect my budget 10 years out, 20 years out or 30
enough, but it isnt… Get this project done today. They`re not sitting there
those dollars do shrink, our operating budgets every year, you know, two

certainty either can be, or should be completely controlled with respect

to energy efficiency investment. Phrases include “we are not going to
purchase it, unless you can show us what your operational budget is going to
that when we have small windows of budgetary requirements.”

be…” (quote (a)), “I wouldn’t take on a project unless I knew it was going to
be successful…” (quote (d)), “they want to make sure there are guarantees
out there” (quote (e)).
The alternate approach to dealing with uncertainty uncovered in the
data results in actions and outcomes that incorporate a longer term,
coordinated vision for energy efficiency led by senior management in
collaboration with multiple departments. Under this approach, inter-
preted as “Managing Complexity”, an environment is fostered that is
strategic and innovating. Risks are not allocated to individuals and
teams, but rather are absorbed by the organization. This results in a risk
Dealing with Uncertainty.

Budgetary pressures
Demanding Certainty

sharing culture, where energy efficiency projects are implementation

operational budget.”

through an ongoing portfolio of projects.

In summary, two opposing approaches of ‘Dealing with Uncertainty’
years out.”

provide a framework for a form of an uncertainty theory in organiza-

tions:
Table 1

1) Managing Uncertainty
b)
a)

c)

2) Demanding Certainty

390
J. Maiorano
The contrasting actions and outcomes associated with the ap-
proaches are outlined below. These opposing approaches are inter-
preted as ideal types. Ideal types, as termed by Max Weber, allow the
subjective motivations of individuals to be interpreted and attached
through their actions. Ideal types have more recently been used to ex-
pand institutional theory through the development of the institutional
logics perspective (see [43]). The actions are categorized along four
processes, including: Framing, Vision, Method and Communication.
The outcomes are compared along four ends: Accountability, Attitude
to Risk and Project Implementation. The categories, actions and out-
comes described below were interpreted from the data and provide a
conceptually abstract theory to answer the second and third research
questions.
6. Actions
6.1. Framing and vision
Within hospitals, structural conditions provide a boundary or a
framework that individuals within this context use to make sense of
energy efficiency. These conditions affect how energy efficiency is
considered, communicated and ultimately the culture that it fosters as
related to energy use and behaviour. The three structural conditions
described above are distilled into frames that Ontario hospitals use for
thinking about energy efficiency. Based on the data, how hospitals deal
with uncertainty under each of these frames, under similar structural
conditions, result in differing approaches to energy efficiency. Table 2
provides a sample of participant responses that highlight these three
frames, describe in more detail below.
6.1.1. Framing through budgetary pressures
When energy efficiency is framed through budgetary pressures,
hospitals find themselves asking: How will investing in or implementing
energy efficiency measures impact our ability to balance our budget?
For some hospitals there are sentiments that upper management is
overwhelmed by the uncertainty and complexity the budget creates,
especially in light of legal implications to balance. Pressures are aug-
mented by a limited sense of control over revenues and expenses, and
worries over the legal implications of not balancing. Hospitals respond
differently to these budgetary pressures and feel differently about their
ability to control them. Some senior managers respond to uncertainty
and lack of control by “Demanding Certainty” within temporal periods,
holding individuals accountable for risks associated with uncertain
outcomes, such as not meeting cost saving projections. This form of
framing is termed “temporal silos”.
6.1.1.1. Temporal silos. “Temporal silos” is a term derived through this
research process to describe the phenomena resulting from the nature
of funding in the public sector. Time, in multiple manifestations, plays a
crucial role in affecting behavior within an organizational context,
especially as related to energy efficiency practices. Implementing
energy efficiency projects take time. This includes: staff time to
organize projects within and across teams, time to co-ordinate
funding, time to source available incentives, time to implement
measures and time to compute measurement and verification (M&V).
Implementation may create interruptions, taking time away from
processes or spaces until completion. Time is needed to educate
technicians, to inform staff or patients, and to learn M&V.
Time is also presented as intervals, for example, projects paybacks
are communicated in intervals of time. Planning, analyzing and
managing within intervals of time was evident in the data as a frame for
thinking, relating, rationalizing and deciding on energy efficiency. This
frame of thinking about energy efficiency is exacerbated by the interval
nature of funding in the public sector, and further so by the balanced
budget requirement which requires revenues and expenses be balanced
in temporal intervals. Temporal silos are intensified further by the lack
391
Energy Research & Social Science 44 (2018) 385–398
of control senior management feels over revenues, and escalating ex-
penses (see quote (g)).
Temporal silos are a frame for decision making under budgetary
pressures. They constrain planning and strategizing and provide ex-
planatory power for delaying or neglecting planning itself. As observed
in the data, many hospitals are stuck in a stage of ‘planning on creating
a plan’. This can result in organizations being in a state of waiting.
Waiting for external sources of funding, waiting to source external in-
centives, external support, external expertise and direction. It also
provides a rationale for blaming others for delays that don’t ascribe to
the temporality they are held to. For example, blaming internal funding
delays, external funding delays, delays of savings between im-
plementation and completion, poor communication causing delays in
grants, and receipts of cash flows that don’t fall within the intervals
they need them to.
Under this frame, clear – almost seamless - communication and
perfect planning are desired outcomes that are almost always un-
attainable due to the lens of temporal silos from which they come. This
creates economically irrational planning, such as for new construction
builds, where short payback/high return investments in energy effi-
ciency measures are not implemented given the complexity of these
costs within the lens of temporal silos. These temporal silos seem in-
escapable for those within them, and add further complexity within
public sector organizations over private sector organizations who are
not susceptible to public sector funding or budgetary policy (see quote
(b)).
Temporal silos seem to be most embedded in finance departments,
demanding certainty of cash flows and concerns about the legal re-
quirement of not balancing their budget. This takes away from strate-
gizing and attaining long term value. In the roundtable discussion, a
hospital manager commented on their experiences dealing with capital
planning teams on energy efficiency investment. Budgetary pressures
and a demand for certainty impede long term investment and risk
taking (see quote (a))
For hospitals that Demand Certainty, framing energy efficiency
through temporal silos distills the vision of energy efficiency as one of
‘lack of resources’ for investing in energy efficiency. These resources
can manifest as a lack of capital, lack of in-house skills, lack of per-
sonnel such as energy managers, lack of time to facilitate, evaluate and
implement opportunities, or to work with external practitioners. Many
researchers have highlighted these manifestations as barriers [14]
however miss the broader context that drive them. For hospitals that
operate under temporal silos, projects with short term paybacks that fit
into budget intervals are considered, but energy efficiency in general
stalls, due to a professed ‘lack of resources’.
6.1.2. Framing through patient care
When energy efficiency is framed through Patient Care, hospitals
find themselves asking: How will investing in or implementing energy
efficiency measures impact our ability to provide patient care?
For some hospitals, energy efficiency and patient care are distinct,
mutually exclusive goals, and they reconcile the two through the lens of
prioritization. Financial pressures and constrained resources compel
them to make a choice, of energy efficiency or patient care, leading to a
lack of priority for efficiency measures. This is the frame of Alternate
Priorities.
6.1.2.1. Alternate priorities. For hospitals that frame energy efficiency
through Alternate Priorities, the decision becomes a comparative
analysis of deciding how best to prioritize funding. Funding for
energy efficiency is juxtaposed against capital invested in improving
patient care, such as medical equipment or other medical innovations.
In addition to the prioritization of funding, hospitals consider how
implementing projects and managing energy supply and demand im-
pact patient care. This includes potential disturbances caused by im-
plementing new equipment, the spaces this may impede, and how this

Table 2
Participant Responses surrounding Energy Efficiency Actions: Framing and Communication.
Demanding Certainty
Temporal Silos
Framing g) “Our issue and I think we are fairly typical, we have access to cash,
credit facility, underused operating line, it isn't so much access to cash,
as to incur additional expense in any additional year, may conflict
with the legal requirement we have to have a non-negative margin, or
black number, balance budget sort of thing… it is not the cash, it is not
the loan itself, it is not the size of the project, it is the impact that the
expense has on our balance budget obligation. So whether that expense
is interest or depreciation if there is long term capital involved then
those are the things that need to be offset by savings, fairly early on in
the project in order to make it neutral, otherwise it is a more
challenging decision to make and would require a conscious decision to
take some additional deficit early on in the project in order to see
larger surpluses later”
h) "One thing we struggle with is when we do a business case with known
funded grants, by the time the business case is done and gone through
the (internal) approval process, sometimes the grant money is gone,
and then we look like we misrepresented ourselves. but there is no
understanding that herf funding (or others) is only for a narrow period
of time and we don't get updated that the funding is only got a few
months left or x amount of dollars. or they don'tndicate ahead of time
392
the limit they have and that its exhaused, though they still accept your
application. poor communication in funding grants."
k) "Having these small windows of "you must balance every year' makes it
more challenging when you have a longer payback period."
j) "We have accountability agreements that require us to have balanced
budgets in one year increments and some of these projects have a
longer payback period than that, so they don't necessarily align with
the legal mandate we have to balance each particular year."
Presenting / Selling / Confirming
Communication s) “But again it’s a tough sell all the way up the chain, and they expect a huge accountability that you will make these targets, and I would rather do stuff
that you know again will show, but that the expectation isn’t anywhere near as stringent.”
t) "You have to get in a position that it becomes something so enticing that they want to put those types of dollars."
u) "The bottom line is if we have a good plan of action and can actually present it to the board showing good data there is good savings, i think this is a tool
that we actually need. we might need some professional assistance with good data or information."
Alternate Priorities
l) "What we have at [organizaton name] is a capital committee – all
different types of capital projects, construction, equipment, medical,
non-medical, we sit down once a year, we look at the pod of capital
available, put a priority tag on it, we'll group it up into an a, b and c
priority, what is risk of not doing it, and then we divvy up the money.
So when you get to a green project, which always ends up in a c, which
is of least priority because its not of critical concern to the next years
operation you have to really [emphasis added] be able to justify a good
payment for people to open their eyes up, and say you know what I am
going to give you x amount of dollars and not then do something
clincal."
m) "Look it makes sense to change the entire mechanical infrastructure in
our c building but I gotta shut down our ORs for 6 months, that's a
none starter, you gotta phase them different ways which may have a
different impact on what you can do, most of them are not an issue but
we have had a few that the barrier in implementation in terms of the
impact on clinical services is just not worth it, and so we have pushed
them off."
n) "In the last 10 years we have spent around 6 million on energy
initiatives, so its really hard to say there is no money available but the
pressure of using those funds versus those funds being used for
something else."
o) "Our challenge is we only get x amount of operating dollars to run the
whole organization, it has to be focused on your core mandate."
J. Maiorano
Managing Complexity
Resiliency
p) "In my mind, there needs to be a bit of a culture change to identify that
managing the facility efficiently is as important to patient care as the new
equipment, the new CT scanners, the MRI, and all those sorts of things.
And I came from DI < digital imaging > and we were always
considered to be the capital hogs in the organization because our
equipment was expensive, we were at the table every year asking for new
things every year because it was a very rapidly evolving technology,
diagnostic services. So the culture is, "Yes, we'll buy the equipment, we'll
get the diagnosis done," and so on. I think there's some education involved
so that we can let the entire organization understand that energy savings
can be reintroduced into patient care, so that we’re not decreasing
programs and cancelling programs, you know, do the funding."
q) "I think if you are going to implement educational and training that's great
to focus on your track units and chillers and boilers and BAS systems and
whatnot. But you need to take that a step further and educate and train on
not only the technical aspects of your building automation, but also how
those technical aspects and how the everyday actions about the greater
staff, have an effect on patient care and what you're doing at the end of
the day. And if you take that and put that together, both the engineering
aspects and the behavioral aspects and make it as one."
r) "So the whole approach now is working more on this global for the
organization, how does it impact the operations, not just dollars."
Collaborating / Negotiating
v) "When you're looking at sustainability as a whole, you need to bring in…
as much as you need to collaborate with all the different departments
within the institution, you also need to bring in all the effects of strategic
sustainability and enterprise management in totality. And that includes
supply chain management, waste and chemical waste, and looking at what
products are coming and going out of the hospital and why. Whether or
not you need them and whether or not you don't."
w) "I can't plan, going forward, my energy usage if people keep buying stuff
and plugging it in. So I basically say: if anything gets plugged in, I want to
know about it. "
x) "It's a cultural change and you don't change culture… it takes seven to 10
years to change culture in an organization. So you need to figure out who
your champion is. They have to be personable, they have to know their
stuff and they have to be out there constantly saying, "This is what we do
and this is why we're doing it."
Energy Research & Social Science 44 (2018) 385–398
J. Maiorano
may slow or stall the delivery of services. New technologies, or more
efficient technologies need to be just as safe for patients. For example,
the impact of air flow on transmission of infection must be considered
when modifying heating, ventilation and air conditioning (HVAC). In
this manner, additional complexity may lead to risks that technology
may fail or cause further disturbances. Projects that don’t succeed have
not only financial impacts, but patient impacts, and are juxtaposed
against resources that could have been used to improve patient care.
The data suggests forms of rationality, or framing of energy effi-
ciency within an institutional and organizational context relate to ac-
tions under uncertainty. Quote (d) in Table 1 describes how a culture
demanding certainty, against the backdrop of patient care, frames
thinking on energy efficiency.
Under the Alternate Priorities frame, capital investment in energy
efficiency is not considered for its long term impact on resiliency of
infrastructure or sustainability, but rather as a process that is accepted
when it does not disturb patient care – or if the financial gain is, as
described by one director of facilities, “so enticing that it gets people to
open their eyes up”. Under this frame energy efficiency is considered,
“low priority”, and progresses with lucrative short term payback pro-
jects that will not risk patient care, while other longer term projects
stall.
6.1.3. Framing through resiliency
Subject to similar structural conditions, some hospitals deal with
uncertainty by “Managing Complexity”. In these hospitals, energy ef-
ficiency and patient care are not viewed as distinct and mutually ex-
clusive, but as co-dependent. Energy efficiency is seen as contributing
to the long term delivery of patient care through resiliency. Interpreted
as ‘Resiliency”, this frame for thinking about energy efficiency enacts
open and clear communication, planning beyond temporal periods, and
ensuring process are designed so that the organization bears risks as-
sociated with uncertain outcomes.
6.1.3.1. Resiliency. A resiliency approach deals with uncertainty
caused by budgetary pressures and a focus on patient care by
managing complexity. To expand thinking beyond short term
budgetary intervals, issues broader than annual cost savings are
considered. Life cycle costing, in a hospital context, includes the
consideration of issues such as equipment reliability, system response,
impact on operations, and the long term resiliency of the infrastructure
delivering patient care to ensure both community health and
environmental sustainability. The data showed that managers in
finance and capital budgeting were more likely to frame decisions
within temporal silos, while operations and clinical service
administrators were more likely to consider energy efficiency more
strategically. Bridging operational silos allows for a greater
understanding of the diverse internal needs, required to manage
budget complexity and strategize over the long term. Operational
efficiencies are improved through an understanding of multiple
departmental needs
Hospitals that managing complexity put weight in the importance of
resiliency, longevity and quality to spur strategic long term decision
making, contrasting with hospitals managing through a demand for
certainty in outcomes. Within hospitals, bridging operational silos may
also involve bridging budgetary silos. As operating and capital budgets
operate independently in most hospitals, facilities or building man-
agement is often left out of decision making. Hospitals that are suc-
cessful in managing budget complexity realize these silos must be
bridged in order to move towards a resiliency approach (see quote (f)).
For hospitals that Manage Complexity under a resiliency frame,
individuals and teams attempt to bridge silos through communication,
collaboration and negotiation amongst other departments.
Organizations align structures, invest in skills, such as energy man-
agers, and create multi-disciplinary teams to better strategize a vision of
how energy efficiency can complement patient care, reduce costs and
393
Energy Research & Social Science 44 (2018) 385–398
provide long term resiliency, innovation and sustainability to the or-
ganization.
6.2. Method and communication
For hospitals that “Demanding Certainty” and frame energy effi-
ciency through temporal silos, energy efficiency projects are considered
a financing item within a risk averse climate. Projects earn cost savings
within temporal windows and capital budgeting teams and facility
managers demand implementation teams present and confirm results,
including energy and cost savings prior to projects being accepted.
Facilities and service teams requesting funds for projects must ‘sell’ the
merits of the project.
Framed through alternate priorities, departments must ‘compete’ for
funding with other departments and funding is prioritized based on its
impact on patient care.
Departments and teams allocate funding for energy efficiency
through an internal prioritization process, which can become compe-
titive amongst departments. Energy efficiency projects in this manner
are presented and ‘sold’ to senior management, or in some cases the
board of directors, under the expectation of certainty. Under this en-
vironment, senior management expects that projected savings be ‘con-
firmed’, and that you will achieve the savings that are presented.
Management is expected to be provided certainty through, as described
by respondents “the use of good data”, and “mathematical formulas”,
expecting individuals and teams to ‘confirm’ the savings are available.
This makes individuals and teams accountable for project risk. As
quoted: “We have to make sure that what we think are the savings are really
the savings".
This can create a disconnect, or a disruption to flow, continuity and
process, in instances where building services indeed perceive inherent
uncertainty in energy efficiency measures, but do not want to be held
accountable for them. As quoted, “But again it’s a tough sell all the way up
the chain, and they expect a huge accountability that you will make these
targets, and I would rather do stuff that you know again will show, but that
the expectation isn’t anywhere near as stringent.”
Given the framing of alternate priorities or lack of resources, there is
limited ‘push’ from leadership, who are not engaged in energy effi-
ciency. Communication, or ‘selling’ is generally from individuals and
teams involved in building services up to management, and rarely top
down. The requirement for hospitals to create conservation and de-
mand management plans has provided opportunities for increased
collaboration between leadership and facilities and operations while
encouraging planning and conservation. Measurement and verification
provide further challenges in ‘confirming’ savings to senior manage-
ment after they have been implemented. It can be difficult to measure
and ‘present’ the actual savings, even if the project is successful.
Under the Managing Complexity approach, leadership buy-in fosters
trust, collaboration, negotiation and data sharing between capital and
operating silos, with operations having input in decision making.
Building needs and service delivery are negotiated through open lines
of communication. M&V is an opportunity to measure energy savings,
understand and improve project implementation, and verify cost sav-
ings and the robustness of processes. As opposed to a discourse that
demands certainty, such as “fixed return” and “guaranteed savings”,
language focuses on “sources of uncertainty” and “risk levels” asso-
ciated with conditions, processes, projects and technologies.
7. Outcomes
As presented so far, at an organizational level, hospitals act differ-
ently depending on both how they frame energy efficiency and how
they respond to uncertainty in their environment. Variation in action
towards achieving energy efficiency are also a result of differences in
how individuals define situations and ascribe meaning to them. Corbin
and Strauss [34] suggest that if people are acting together to reach a
 J. Maiorano

Table 3
Participant Responses Surrounding Energy Efficiency Outcomes.
Demanding Certainty Managing Complexity

Risk Avoiding Risk Sharing

Organizational Attitude to Risk
y) “We have to make sure that what we think are the savings are really the savings." ab) "So we … kind of get all that data together and make it transparent at all levels so the end-users, the
z) "You are living on the edge when you are putting something to senior management. Something that is operators, the financial decision-makers upstairs, the people in capital development, because really
going to save money." that data, just to collect it, doesn't do you any good. You have to be using it … But to make sure that all
aa) "I could probably convince them, provided you know that I had the backing of detailed studies and the decision-makers, like I said, from the frontline all the way up, are turning around and able to use
guarantees." that data on it there."

Individuals Absorb Risk Organization Absorbs Risk

Accountability ac) "It’s a catch 22 for me, do I want to do the project and lose the money? It is a risk. They don’t see if it af) "All levels of the organization operating are able to factor the lifecycle cost."
works, they assume that I am right and I will make the savings. If my bottom line is in the red, that’s a
reflection of me, I have to find a way to balance my budget."
ad) "We haven’t but we are thinking of doing it now. We have to make sure that what we think are the
savings will really be the savings. If you are borrowing 10 years, and you are supposed to be done you
want to make sure you are not taking $ from other areas to pay that loan."
ae) "would it be better to take the loan and just "bite the bullet" and get things done."

394
Shorter payback / Incremental Approach Longer Term Payback / Portfolio of Projects
Project implementation ag) “One of the rule of thumb was if you can get the payback in 10 years it was a good deal. But ai) The current president they believe in energy management and energy efficiency, and we have
now it is 3 to 5 years, … now that they are now liable for their budget so that is why they are had such success over the years that when we come forward with an energy project it is
running everything tight.” accepted with open arms and we are able to get funds and all those kinds of things. But the
ah) … as the director of the facility …you are totally accountable for the paybacks. Some have done bottom line is, it still has to have a reasonable payback. And for us a reasonable payback, our
million dollar projects on energy retrofit projects, you do have to get board approval for last project was an 8 year, so we have gone well beyond the 4 or 5 year paybacks
millions of dollars – the board expects to see this – it becomes a risk to my own job. If it doesn’t
work, perhaps my operators don’t see it as right equipment – but I take the hit – am I willing in
my young career to stick my neck out after I have seen a few hospitals lose their directors, you
know indirectly to that, it probably won't be me, I would rather do it in a systematic way, get
traction, which I have now, use dollars we have where, and keep it out of the boards eye… I
can’t name any names, but I have been around for a couple years at this level now the rationale
for the final re-location or move of a person – at least two have been because of failed green
energy projects… They were there for 15 years, then they went into a big massive project that
did not pan out … it didn’t work with the Canadian environment, the weather here is way too
tough on some of the projects that get proposed some time, and then they were for undisclosed
reasons moved out, but they of course know the real reasons and eventually when they moved
to the next job will whisper … as to why they were let go.
Energy Research & Social Science 44 (2018) 385–398
J. Maiorano
Table 4
Actions and Outcomes Resulting from Two Approaches to Dealing with Uncertainty.
Demanding Certainty
Conditions: Structural Conditions Budgetary Pressures
Framing Temporal Silos
Vision Lack of Resources
Actions: Method Financing
Communication
Outcomes: Organizational Attitude to Risk
Accountability Individuals Absorb Risk
Project Implementation
Incremental Approach
goal or manage a problem, they must bring their actions or responses
into alignment or the flow and continuity will be disrupted. In a similar
manner, this research found that variation in outcomes result both
within differences in meanings and responses to uncertainty ascribed at
the individual level, and given difference in framing and dealing with
uncertainty at the organizational level. As mentioned, the approaches
presented, Demanding Certainty and Managing Complexity, are points
in a spectrum and are not ends in themselves. Hospitals are considered
to use approaches somewhere within this spectrum. Outcomes related
to the following: Organizational Attitude to Risk, Accountability and
Project Implementation were identified in the data as aligning with the
frames and approaches interpreted. Table 3 presents select participant
responses, intended to provide insights into these outcomes. Theoretical
findings and connections are substantiated by the broader methodolo-
gical approach and data collection.
7.1. Organizational attitude to risk and accountability
Hospitals that Demand Certainty foster an environment that is risk
avoiding. Certainty of outcomes allow senior management to plan,
forecast and be assured they will meet their budgetary targets and be
able to deliver on their plans for patient care. This need for certainty
increases expectations on individuals, affecting their approach and
decision making. This can cause facilities and services to feel a sense of
uneasiness or vulnerability when presenting energy efficiency measures
to management, and can result in higher degrees of risk aversion, and
reluctance to formulate and present energy efficiency projects in de-
manding certainty environments. The following director of facilities
and services shares how his attitude towards risk avoidance is shaped
both by the expectations placed on him, and knowledge of incidents
occurring at other hospitals under similar situations. Other hospital
facility directors had absorbed implementation risk of projects, and in
some instances lost their jobs due to these risks (see quote (ah)):
Hospitals that demand certainty shift risk and accountability onto
individuals, teams and departments. A catch 22 situation is described
by the director (different to the earlier participant that referred to a
catch 22) to summarize the circumstances surrounding energy effi-
ciency within a demanding certainty environment: It’s a catch 22 for me,
do I want to do the project and lose the money? It is a risk. They don’t see if it
works, they assume that I am right and I will make the savings. If my bottom
line is in the red, that’s a reflection of me, I have to find a way to balance my
budget.
A rationalist perspective might use agency theory to suggest orga-
nizations are lacking appropriate contracts designed with sufficient
individual incentives, or are designed with an asymmetric rewards
function. The data do suggest an asymmetric reward function; that
395
Energy Research & Social Science 44 (2018) 385–398
Managing Complexity
Patient Care Budgetary Pressures & Patient
Care
Alternate Priorities Resiliency
Low Priority Complementary to Patient Care
Driving Resiliency
Competing Strategizing
Innovating
Presenting Negotiating
Selling Collaborating
Confirming
Risk Avoiding Risk Sharing
Organization Absorbs Risk
Shorter Payback Longer Term Payback
Portfolio of Projects
individuals will not get duly praised for successes in energy efficiency
but will bear consequences in the event of failure. However the data
further suggest that individuals are expected to control sources of un-
certainty that may not be controllable, or to absorb risks that were
beyond their control.
While holding employees accountable for financial losses may not
be unexpected, hospitals that Manage Complexity ask broader questions
regarding the extent that uncertainty associated with energy efficiency
measures are controllable. Open communication explores how teams
can develop expertise to mitigate risks identified, and to manage which
aspects of certain processes, such as energy efficiency implementation,
for which individuals and teams are held accountable. Information
sharing, strategic planning and negotiating amongst departments and
teams allow departments to bridge operational silos and expand plan-
ning beyond temporal silos, in order to galvanize innovation under
unpredictable circumstances. Staff and teams are assured they will be
held accountable for their evaluation and assessment of the benefits and
risks associated with energy efficiency, and not exclusively with out-
comes.
7.2. Project implementation
As described earlier, for hospitals that frame energy efficiency under
temporal silos, only projects with short term paybacks that fit into
budget intervals are considered. Energy efficiency over a longer term
horizon stalls due to a professed ‘lack of resources’ and an inability to
plan and time cost savings with additional expenses.
For hospitals that frame energy efficiency under alternate priorities,
energy efficiency is given “low priority”, and progresses with lucrative
short term payback projects that will not risk patient care, while the
implementation of longer term projects stall.
For hospitals that Manage Complexity collaboration, negotiation
and data sharing allow capital and operating silos, to be bridged.
Energy efficiency and patient care are not seen as disparate goals, but
rather the importance of resiliency, longevity and quality spur strategic
long term decision making. This leads to the implementation of energy
efficiency projects with energy savings and infrastructure improve-
ments over both the short term and longer term.
This discussion is not to suggest that hospitals should prioritize
energy efficiency over investment or innovation in patient care.
However, it does theorize how variation in dealing with uncertainty
and in framing structural conditions can result in delays, or the dis-
missal of seemingly prudent long term cost, energy and GHG saving
practices.
Table 4 below provides a summary of the theoretical findings. This
provides a form of an uncertainty theory in organizations, reflecting
J. Maiorano
how alternate forms of rationality, and alternate ways of dealing with
uncertainty, namely Demanding Certainty and Managing Complexity,
result in variation in actions and outcomes surrounding energy effi-
ciency in Ontario hospitals.
8. Discussion
To broaden understanding of the dynamics surrounding energy ef-
ficiency practices in organizations, this research explored dynamics at
multiple levels, exploring the influence of broader institutional pres-
sures on hospitals, organizational approaches to uncertainty and forms
of rationality, and individual behavior within an organizational con-
text. The identification of structural conditions informed the influence
of the broader context, and has ties to institutional theory and resource
dependency theory. The framing of energy efficiency through bud-
getary pressures suggests alignment with a resource dependency theory
of seeking stability and predictability in order to mobilize resources and
reduce uncertainty [44,45] whereas framing through alternate prio-
rities stemming from normative elements of patient care and steward-
ship or logics of appropriateness [46], align with institutional theory
where organizations seek social legitimacy [47].
The findings suggest that, as energy efficiency is not a primary goal,
hospitals frame energy efficiency in terms of pressures from their en-
vironment and their own mission, such as a patient care logic. Theory
by Oliver [45] suggests that due to dependency on funding, hospitals
will conform to these pressures. Oliver [45] identifies strategic re-
sponses organizations enact in responding to institutional pressures.
While hospitals are under similar institutional pressures from highly
legitimate sources, such as government or professional norms, Oliver
suggests that both the content of pressures (ie. goal alignment, volun-
tary vs. legal) and the degree of environmental uncertainty, affect an
organization’s resistance or conformity to institutional pressures. In-
deed, how hospitals frame energy efficiency, reflect the degree they
believed energy efficiency requirements aligned with their organiza-
tional goals. Hospitals that demanded certainty felt strong normative
and budgetary pressures, and conformed to institutional funding pres-
sures, such as balancing the budget. The relationship for energy effi-
ciency is a different form of institutional pressure. It is not a hard
regulatory requirement, such as through emissions targets, but rather a
matter of publishing annual levels of energy consumption through a
CDM plan.
This paper provides a theory for why energy efficiency practices
within hospitals differ by interpreting the various ways hospitals in-
terpret structural conditions to frame energy efficiency, and the alter-
nate approaches hospitals use to deal with the uncertainties they face.
While barriers such as lack of capital, access to resources, lack of
priority or financial risk have been identified by researchers (Sorrel
et al., 2004) this paper explores both the underpinnings to these bar-
riers and the role framing and uncertainty play in bringing them about.
One area for future researchers surrounds further exploring the role
uncertainty plays amongst the duality between logics and practices (see
[43]). These findings suggest heterogeneity in practices of organiza-
tions under similar institutional pressures can be uncovered by ex-
ploring, not only alternate forms of rationality or logics, but also how
these forms relate to alternate ways they respond to uncertainty in their
environment. In the uncertainty theory derived in this study, some
organizations are found to demand certainty. This is not a function of
control over individuals, teams or members, but rather a form of control
over outcomes and practices. In this manner, demanding certainty over
outcomes results in externalization of associated risks to individuals,
teams or departments over the organization itself. Alternatively, other
organizations deal with uncertainty by managing complexity, with the
organization absorbing associated risks from uncertainty of practices,
resulting in more collaborative approaches and more innovative and
longer term decision making horizons.
This paper also provides context for how risk can be transferred by a
396
Energy Research & Social Science 44 (2018) 385–398
principal to an agent, pressured through frames and driven by a de-
mand for certainty. To be clear, the demand for certainty was not in-
terpreted as coercive control, or an outright conscious decision to
transfer risk, but rather stemmed in part from a positivist ontological
view of reality, that the external environment can be controlled, and
that it is the agent’s responsibility to be able to assess, understand and
control uncertainties in the environment, even when some uncertainties
may be beyond control. There is evidence that institutional pressures
drive these organizational pressures and in this manner, an approach to
dealing with uncertainty provides a structural form. A provincially
mandated balanced budget policy, a policy stemming perhaps from fi-
nancial prudence, and also perhaps from mistrust and financial control,
has untended consequences for innovation and risk aversion. The policy
handcuffs hospitals of financial flexibility, exacerbating environments
that demand certainty.
This paper aligns with Hoffman’s findings on how differing frames
are enacted by organizations in different sectors surrounding environ-
mental concerns, informing resistance to environmental practices
[17,18]. Hoffman [17] argues that to understand varying organiza-
tional responses to institutional pressures, researchers need to under-
stand both from which stakeholder in the organizational field that the
concern arises, the cultural framing of the concern, and how structural
and cultural routines in organizations enact the incoming pressure [17].
Similarly, Biggart and Lutzenhiser [18] contend that implementation of
energy efficiency measures in buildings are often not rooted in decision
making focused on economic rationality. Rather, they are rooted in
cultural frames. They conclude most significant contributions to im-
proved energy efficiency have likely been in institutional under-
standings providing context to economic choices by firms and govern-
ments, over economic ideas such as improving building efficiency or
finding economic incentives to reduce hurdle rates.
In line with these approaches, the Energy Cultures Framework
suggests that energy behavior can be understood by exploring the in-
teractions between cognitive norms and beliefs, material culture and
energy practices and processes [48]. Amongst this interacting system,
there are wider systemic cultural and institutional influences on beha-
vior. They hypothesize that distinctive clusters of similarly acting
norms, material culture and practices will be observable and have some
bearing on the way energy is used, and that “…stabilisation of behavior
occurs, where norms, practices and technologies are aligned – that is,
where the dynamics between the three components are self-enforcing”
(p. 6125). Applying this framework to the findings in this research
setting, while there may be similarity amongst aspects of the energy
cultures within Ontario hospitals, given similar institutional and reg-
ulatory pressures and the physical design of hospital spaces, distinctive
cultures can form based on differences in the interactions between
norms centered around patient care, fiscal conservativeness, physical
hospital characteristics, energy practices affected by local energy
supply, and maintenance of technologies. This research aligns to a
certain extent, through the notion of different types of clusters forming
within similar energy context, offering several different ideal types,
suggesting how energy decision making can occur.
Findings from behavioural science are also relevant to the findings
in this study. With respect to the Allais paradox, Allais [49] asked
participants to choose between two choices, a 100% chance of winning
100 million francs or a probability weighted scenario including an 89%
chance of winning 100 million francs, a 10% chance of winning 500
million francs and a 1% chance of winning nothing. Despite the second
scenario providing a higher expected payback, most participants chose
the former, resulting from risk aversion or “the preference for security
in the neighbourhood of certainty” ([50], p.6). However, when parti-
cipants were asked if they prefer an 89% chance at nothing and an 11%
chance at 100 million francs, versus a 90% chance at nothing and a 10%
chance at 500 million francs, most chose the latter, implying in-
dividuals can be risk seeking and risk averse.
In prospect theory, building on Allais’ findings and findings of their
J. Maiorano
own developed through observations Kahneman and Tversky [51]
theorize a value function reflecting predictable preferences for risk
seeking and risk averse behavior that diverts from expected utility
theory. They find people normally perceive outcomes as gains and
losses, defined relative to some neutral reference point, rather than as
final states of welfare. Kahneman and Tversky suggest framing affects
choice under uncertainty through the classic experiment where a de-
cision is asked of a participant under two scenarios which present the
same choice, only stated in different terms. Subjects drastically change
their selection of a program to fight a disease outbreak if the scenario
and outcomes are phrased in terms of probabilities assigned to people
being ‘saved’ versus probabilities assigned to people that will ‘die’ with
certainty. Under these framing effects [51] decision making can be
based on the potential value of losses and gains, and not on the ex-
pected outcome [51]. In this manner, how scenarios are framed in
terms of uncertainty result in different outcomes. The results of this
paper apply a similar framing effect, however within an organizational
context: that organizations within the same institutional environment
frame structural conditions differently, and because of this, deal with
uncertainty differently, resulting in heterogeneity of organizational
practices.
A second possible outcome to test, that is beyond the scope of the
research methods of this paper, is whether organizations are both risk
seeking and risk averse, and does this depend on how they frame
structural conditions, in particular in relation to their mission, or in
relation to instrumental versus value-rational goals (zweckrationalist
vs. wertrationalitat) (see Weber [52], O’Connell et al. [53])? Do orga-
nizations think about gains and losses over the long term (resiliency),
while others define it relative to a neutral reference point? In this
manner, can these affects hold within the context of organizational
decision making?
For example, in this study, for hospitals that frame energy efficiency
in terms of alternate priorities, it aligns that they are more risk-averse if
it involves potential gains (in instrumental goals) associated with en-
ergy efficiency. But if a loss is likely in terms of a value-rational goal, for
example in delivering patient care, do they become more risk-seeking in
purchasing patient related medical equipment and devices?
This paper also aligns with findings from agency theory, which fo-
cuses on a contractual relationship formed between a principal who
delegates tasks to an agent, and the agency costs that arise because the
two parties may have different interests [54]. One source of agency
costs results from differences in risk propensities between principals
and agents. The theory calls for the principal, to design an appropriate
incentive structure to ensure appropriate cooperation by the agent.
Rappaport [55] conceptualizes ideas related to agency theory and risk
aversion within the context of corporate executive compensation. He
questions whether it is reasonable to assume that corporate executives
acting as economic agents, have a lower tolerance for risk than their
shareholders, the principals. DeCanio [13] draws on this argument to
reason that executive compensation may skew decisions away from
beneficial energy efficiency investments, both due to these differing
levels of risk aversion, and if the personal consequences of failure are
larger than the payoff of success. This phenomenon is indeed found in
the data in this study, however this study departs from a rationalist,
economic perspective normally used to explore alternate risk propen-
sities focused on improving incentive structures. Instead this research
draws on calls from Nilakant and Rao [56] to incorporate organiza-
tional theory approaches to exploring uncertainty, and suggests context
and framing provide a boundary for decision making and framing un-
certainty, affecting these differing levels of risk aversion at the in-
dividual level. At the organizational level, these frames, and the alter-
nate ways they affect approaches to dealing with uncertainty, result in
heterogeneity in practices.
Lastly, this research introduces the concept of ‘temporal silos’ as a
frame impeding innovation in decision making. Behavioural economics
explores time inconsistencies and hyperbolic discounting, such that
397
Energy Research & Social Science 44 (2018) 385–398
individuals make different decisions, when put in the same situation at
a later time, while classic decision-making theory assumes discount
rates and preferences are independent of the date of the decision.
Spurred by funding policy and budgetary pressures in the sector, some
hospitals frame decision making under ‘Temporal Silos’ resulting in
time inconsistent decision making in the government sector. While
governments strive for financial prudence and efficiency, the under-
pinnings that drive these temporal pressures at the government funding
level should be further explored to better assess the trade-offs between
the benefits of budgetary discipline and the suppression of financial
flexibility and innovation – especially with respect to sustainability
related decision making. While in this paper it was found that certain
institutional pressures cause this framing, the extent temporal silos act
as a frame that stall energy efficiency and innovation in organizations
beyond the government sector should be further explored.
9. Conclusion
Through a social science approach rooted in grounded theory, this
research begins a form of an uncertainty theory in organizations, ex-
ploring how alternate forms of rationality and dealing with uncertainty
result in variation in actions and outcomes surrounding energy effi-
ciency in Ontario hospitals. Three structural conditions were inter-
preted from the data, including Patient Care, Budgetary Pressures, and
Issues of Control, which drive alternate frames for considering energy
efficiency. Hospitals that approach uncertainty by demanding certainty
use one of two frames: framing energy efficiency through temporal silos
or through alternate priorities. Under the temporal silos frame, a hos-
pital’s vision for energy efficiency is one of ‘Lack of Resources’, and
their method to advance energy efficiency is driven by a ‘Financing’
approach. Under the alternate priorities frame, the vision for energy
efficiency is one of ‘Low Priority’ and their method to advance energy
efficiency is accomplished by ‘Competing’ internally for resources.
Hospitals that ‘Demand Certainty’, communicate internally by pre-
senting, selling and confirming, resulting in risk avoiding organizations,
where individuals absorb risks from energy efficiency. In these hospi-
tals, energy efficiency projects are implemented over short term hor-
izons and longer term projects stall.
Hospitals that deal with uncertainty by ‘Managing Complexity’ en-
vision energy efficiency as complementary to patient care, driving re-
siliency, bridging organizational silos and expanding thinking beyond
temporal intervals. These hospitals communicate through negotiation
and collaboration, fostering shared meanings surrounding the eco-
nomic, environmental and co-benefits of energy efficiency. In these
hospitals, organizations absorb risks associated with energy efficiency
leading to the advancement of longer term energy efficiency projects.
Further research through alternate methodological approaches in-
cluding quantitative methods is required to continue to explore re-
lationships between forms of rationality and processes to deal with
uncertainty in organizations.
References
[1] Intergovernmental Panel on Climate Change, Climate Change 2013: The Physical
Science Basis. Working Group I Contribution to the Fifth Assessment Report of the
Intergovernmental Panel on Climate Change, Cambridge University Press, 2013.
[2] UNEP (United Nations Environment Programme), Buildings and Climate Change:
Status, Challenges and Opportunities, (2007).
[3] Province of Ontario, Climate Change Action Plan, Retrieved from: (2016) https://
www.ontario.ca/page/climate-change-action-plan.
[4] D. Kolokotsa, T. Tsoutsos, S. Papantoniou, Energy conservation techniques for
hospital buildings, Adv. Build. Res. 6 (1) (2012) 159L.
[5] Ontario Data Catalogue, Energy Use and Greenhouse Gas Emissions for the Broader
Public Sector. [data file], Retrieved from: (2017) https://www.ontario.ca/data/
energy-use-and-greenhouse-gas-emissions-broader-public-sector.
[6] International Energy Agency (IEA), World Energy Outlook 2008, OECD/IEA, Paris,
2008.
[7] World Health Organization (WHO), Healthy Hospitals – Healthy Planet – Healthy
People: Addressing Climate Change in Health Care Settings, A discussion draft
J. Maiorano
paper published by the World Health Organization and Health Care Without Harm,
(2007).
[8] Jefferson, Energy Efficiency Opportunities in Ontario Hospitals. OHA Energy
Efficiency, (2006) Retrieved from: http://studylib.net/doc/18873604/energy-
efficiency-opportunities-in-ontario-hospitals.
[9] A.B. Jaffe, R.N. Stavins, The energy-efficiency gap: what does it mean? Energy
Policy 22 (1994) 804–810.
[10] P. Crittenden, New Perspectives on Institutional Change: The Case of Changing
Energy Management Practices in Australia, PhD in Management Thesis, UTS
Business School, Sydney, 2014.
[11] M.A. Brown, Market failures and barriers as a basis for clean energy policies, Energy
Policy 29 (14) (2001) 1197–1207.
[12] P.B. Cebon, Twixt cup and lip organizational behaviour, technical prediction and
conservation practice, Energy Policy 20 (9) (1992) 802–814.
[13] S.J. DeCanio, Barriers within firms to energy-efficiency investments, Energy Policy
21 (1993) 906–914.
[14] S. Sorrell, E. O’Malley, J. Schleich, S. Scott, The Economics of Energy Efficiency —
Barriers to Cost-effective Investment, Edward Elgar, Cheltenha, 2004.
[15] S.J. DeCanio, The efficiency paradox: bureaucratic and organizational barriers to
profitable energy saving investments, Energy Policy 26 (1998) 441–454.
[16] E.H. Schein, The concept of’ client’ from a process consultation perspective. A guide
for change agents, J. Org. Change Manage. 10 (1997) 3.
[17] A.J. Hoffman, Linking organizational and field-level analyses: the diffusion of
corporate environmental practice, Org. Environ. 14 (2) (2001) 133–356.
[18] N.W. Biggart, L. Lutzenhiser, Economic sociology and the social problem of energy
inefficiency, Am. Behav. Sci. 50 (8) (2007) 1070–1087.
[19] S.C. Breukers, E. Heiskanen, B. Brohmann, R.M. Mourik, C.F.J. Feenstra,
Connecting research to practice to improve energy demand-side management
(DSM), Energy 36 (4) (2011) 2176–2185.
[20] T. Bye, A. Bruvoll, Multiple instruments to change energy behaviour: the emperor’s
new clothes? Energy Effic. 1 (4) (2008) 373–386.
[21] M.A.R. Lopes, C.H. Antunes, N. Martins, Energy behaviours as promoters of energy
efficiency: a 21st century review, Renew. Sustain. Energy Rev. 16 (6) (2012)
4095–4104.
[22] M. Moezzi, K.B. Janda, From “if only” to “social potential” in schemes to reduce
building energy use, Energy Res. Soc. Sci. 1 (2014) 30–40.
[23] L. Lutzenhiser, Through the energy efficiency looking glass, Energy Res. Soc. Sci. 1
(2014) 141–151.
[24] R. Andrews, E. Johnson, Energy use, behavioral change, and business organizations:
reviewing recent findings and proposing a future research agenda, Energy Res. Soc.
Sci. 11 (2016) 195–208.
[25] R. House, D. Rousseau, M. Thomas-Hunt, The meso paradigm: a framework for the
integration of micro and macro organizational behaviour, Res. Organ. Behav. 17
(1995) 71–114.
[26] Ontario Ministry of Energy (2018), found at: http://www.energy.gov.on.ca/en/
green-energy-act/conservation-for-public-agencies/ (Accessed: February 2018).
[27] Canadian Coalition for Green Health Care (CCGHC), Green Hospital Scorecard:
Final Project Report, Retrieved from: (2017) http://greenhealthcare.ca/ghs-
2016/#casestudies.
[28] Ontario Data Catalogue, Greenhouse Gas Emissions Reporting by Facility. [data
file], Retrieved from: (2018) https://www.ontario.ca/data/greenhouse-gas-
emissions-reporting-facility.
[29] OHA (Ontario Hospital Association), Cap-and-Trade Program Legislation Update,
found at: (2017) Accessed: June, 2017 https://www.oha.com/legislative-and-legal-
issues/hospital-policies-and-operations.
[30] B.G. Glaser, A.L. Strauss, The Discovery of Grounded Theory: Strategies for
Qualitative Research, (1967), p. 86.
[31] K. Charmaz, L.L. Belgrave, Qualitative interviewing and grounded theory analysis,
The SAGE Handbook of Interview Research: The Complexity of the Craft, (2012),
pp. 347–366, http://dx.doi.org/10.4135/9781452218403.n25.
[32] K. Charmaz, Constructionism and the grounded theory, in: J.A. Holstein,
J.F. Gubrium (Eds.), Handbook of Constructionist Research, The Guildford Press,
New York, 2008, pp. 397–412.
[33] M.Q. Patton, Qualitative Research and Evaluation Methods, Thousand Oaks,
California, 2002.
[34] J. Corbin, A. Strauss, Basics of Qualitative Research: Techniques and Procedures for
Developing Grounded Theory 3 (2008).
[35] Minister of Finance, 2016 Ontario Budget, Retrieved from: (2016) http://www.fin.
gov.on.ca/en/budget/ontariobudgets/2016/ch3b.html#c3-24.
[36] Ministry of Health and Long-Term Care (MOHLTC), About the Excellent Care for All
Act, Retrieved from: (2016) http://www.health.gov.on.ca/en/pro/programs/ecfa/
funding/hs_funding.aspx.
398
Energy Research & Social Science 44 (2018) 385–398
[37] Ministry of Health and Long-Term Care (MOHLTC) (2016). Ministry of Health and
Long-Term Care (MOHLTC) Patient Based Funding: Overview. Retrieved from:
http://www.drdh.org/Documents/4_MOHLTC_Patient_Based_Funding_Overview.
pdf.
[38] Ministry of Health and Long-Term Care (MOHLTC), About the Excellent Care for All
Act, Retrieved from: (2016) http://www.health.gov.on.ca/en/pro/programs/ecfa/
legislation/act.aspx.
[39] MOHLTC, Ministry-lhin Accountability Agreement: April 1, 2015 – March 31, 2018,
(2016).
[40] A. Odutayo, J. Petch, A. Laupacis, Health Care in Ontario: A Primer for Hospital
Board of Directors, found at: (2013) Accesssed: Dec, 2016 https://www.thegce.ca/
COMMUNITY/Documents/Healthy%20Debate.pdf.
[41] J. Holton, The coding process and its challenges, in: A. Bryant, K. Charmaz (Eds.),
The Sage Handbook of Grounded Theory, Sage Publications, 2007.
[42] B.G. Glaser, Remodeling grounded theory [80 paragraphs], with the assistance of
Judith Holton, Forum Qual. Sozialforschung/Forum: Qual. Soc. Res. 5 (2) (2004) 4
http://nbn-resolving.de/urn:nbn:de:0114-fqs040245.
[43] P.H. Thornton, M. Lounsbury, W. Ocasio, The Institutional Logics Perspective: a
New Approach to Culture, Structure and Process, Oxford University Press, Oxford,
2012.
[44] J. Pfeffer, G.R. Salancik, External Control of Organizations: A Resource Dependence
Perspective, Harper & Row Publishers, London, 1978.
[45] C. Oliver, Strategic responses to institutional processes, Acad. Manage. Rev. 16 (1)
(1991) 145–179, http://dx.doi.org/10.5465/amr.1991.4279002.
[46] J.G. March, J.P. Olsen, The logic of appropriateness, in: M. Moran, M. Rein,
R.E. Goodin (Eds.), The OXford Handbook of Public Policy, Oxford University Press,
USA, 2006, pp. 689–708.
[47] P.J. Dimaggio, W.W. Powell, The iron cage revisited: institutional isomorphism and
collective rationality in organizational fields, Am. Sociol. Rev. 48 (2) (1983) 147.
[48] J. Stephenson, B. Barton, G. Carrington, D. Gnoth, R. Lawson, P. Thorsnes, Energy
cultures: a framework for understanding energy behaviours, Energy Policy 38 (10)
(2010) 6120–6129, http://dx.doi.org/10.1016/j.enpol.2010.05.069.
[49] M. Allais, Le comportement de l’homme rationnel devant le risque: critique des
postulats et axiomes de l’ecole americaine, Econometrica 21 (4) (1953) 503–546.
[50] M. Allais, An outline of my main contributions to economic science, Am. Econ. Rev.
87 (6) (1997) 3–12.
[51] D. Kahneman, A. Tversky, Prospect theory: an analysis of decision under risk,
Econometrica (1979) 263–291.
[52] M. Weber, Economy and Society, University of California Press, Berkeley, 1978.
[53] L.L. O’Connell, C.U. Stephens, M. Betz, J.M. Shepard, J.R. Hendry, An organiza-
tional Field approach to corporate rationality: the role of stakeholder activism, Bus.
Ethics Q. 15 (01) (2005) 93–111.
[54] M.C. Jensen, W.H. Meckling, Theory of the firm: managerial behavior, agency costs
and ownership structure, J. Finance Econ. 3 (4) (1976) 305–360.
[55] A. Rappaport, Executive incentives vs. corporate growth, Harv. Bus. Rev. 56 (No 4)
(1978) 81–88.
[56] V. Nilakant, H. Rao, Agency theory and uncertainty in organizations: an evaluation,
Org. Stud. 15 (5) (1994) 649–672.
[57] Environment Canada, National Inventory Report 1990-2015: Greenhouse Gas
Sources and Sinks in Canada, PART 1 (NIR), (2017) Ottawa.
[58] A.J. Hoffman, R. Henn, Overcoming the social and psychological barriers to green
building, Org. Environ. 21 (4) (2008) 390–419.
[59] P. Rohdin, P. Thollander, P. Solding, Barriers to and drivers for energy efficiency in
the Swedish foundry industry, Energy Policy 35 (1) (2007) 672–677.
[60] B. Paton, Efficiency gains within firms under voluntary environmental initiatives, J.
Clean. Prod. 9 (2) (2001) 167–178.
[61] R. Friedland, R. Alford, Bringing society back symbols, practices, and institutional
contradictions, in: W.W. Powell, P.J. DiMaggio (Eds.), The New Institutionalism in
Organizational Analysis, University of Chicago Press, USA, 1991, pp. 232–263.
[62] F. Dobbin, The New Economic Sociology: A Reader, Princeton University Press,
USA, 2004.
[63] E. Shove, L. Lutzenhiser, S. Guy, B. Hackett, H. Wilhite, Energy and social systems,
in: S. Rayner, E. Malone (Eds.), Human Choice and Climate Change, vol. 2, Battelle
Press Columbus, USA, 1998.
[64] J. Ueckermann, Green initiatives in hospitals in Ontario: Is there a business case?
Master of Business Administration Thesis, University of Stellenbosch, South Africa,
2011.
[65] K. Charmaz, Constructing Grounded Theory: A Practical Guide Through Qualitative
Analysis, Sage Publications, UK, 2006.
[66] J. Lofland, L.H. Lofland, Analyzing Social Settings: A Guide to Qualitative
Observation and Analysis, 3rd edition, Wadsworth Publishing, USA, 1995.