At the end of 2014, a large university hospital in the Netherlands launched a procurement tender exercise for surgical suture material. The rationale for
hospital management to initiate this procedure was cost-cutting and standardization. The award criteria were focussed on the most economically
advantageous tender. There were different suppliers on the market that were able to produce and deliver high-quality surgical suture material for a
lower price than was currently being paid. Consequently, the tender was awarded to a new supplier. The top managers and purchasing manager who
initiated the tender trod carefully and implemented this relatively small-scale change initiative according to some basic change management principles
(e.g. Kotter, 2012): they built a guiding coalition that incorporated renowned medical specialists, they consulted department heads and they
communicated the change to surgeons through different channels. Furthermore, it was recorded in the tender that the new supplier should provide
value-adding services such as e-learning modules for surgeons, facilitate lengthy trial-use periods and offer workshops and support to the operating
theatre. Hospital management conceived this first initiative as a test case for more extensive cost-cutting operations that were to follow. This project
was supposed to be relatively easy, both in scale and in complexity. However, in the preparations ahead of the trial phase, a concern was raised by the
cardiac surgeons to one part of the tender package involving sutures specifically used for cardiac surgery. Nevertheless, surgeons were forced to
participate in testing the products supplied in the whole tender, including those products used in their specific specialities. Meanwhile, the initiators of
the project felt that careful preparations of the testing phase had been made.

So, what went wrong? In mid-2015 – when this research project started – hospital management eventually met with fierce resistance from some of the
hospital’s cardiothoracic surgeons. They adamantly refused to work with the new suture material. The resistance took the form of surgeons expressing
anger at management, stockpiling their own supplies of surgical suture, refusing to operate, holding managers accountable for patient deaths that could
arise from use of the new suture and threatening to go to the press if such a thing indeed were to happen. Hospital management had anticipated some
resistance, but not of this intensity. The end result was that the contract was eventually cancelled for sutures specifically used in cardiac surgery.

Data collection

Data collection took place in a year starting from mid-2015. In total, 17 in-depth interviews were conducted that each lasted approximately 1 h. The
respondents were targeted through maximum variation sampling until saturation was achieved and are listed in Table I. Patients were exc

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