In this paper we examine how two different strategic changes influence the Management Control Systems in six Ontario based hospitals. These changes are: 1. new funding regimes based on Ontario Case Costing and, 2. Lean Healthcare initiatives in Ontario Hospitals.

The Ontario Case Costing (OCC) approach is based on the traditional MAS assumption that more accurate costs will lead to lower costs through better management decisions of some sort. In contrast, Lean Healthcare is premised on the assumption that the primary path to better performance is realized by individual employees, who serve as the leading actors in a daily process of waste removal and efficiency improvement.

Based on the MA literature and on information about both the OCC and Lean Healthcare initiatives, we expect there to be significant frictions inside the financial management staff as well as between the Lean initiative and the financial management staff related to the OCC mandate. This study examines this set of interactions to learn how these issues impact the employees involved. In particular, the Ontario context allows us to examine the variety of responses to the interaction of Lean healthcare strategy and a traditional MAS such as OCC.

We find that the MASs of hospitals in our sample are too loosely coupled to develop the frictions indicated by traditional MAS theory and propose modifications in application of the theory to accommodate this observation.