Governance absorption of volume-based procurement: study of dual-track implementation in a public hospital

Volume-based procurement (VBP) is commonly premised on a linear transmission assumption, whereby restructuring procurement rules and price mechanisms is expected to drive clinical substitution. In practice, however, hospital-level change often displays differentiation, phasing, and reversibility, suggesting that policy effects do not simply descend in a linear fashion. This article aims to identify the mechanisms through which policy directives are translated at the hospital organizational level and proposes a governance absorption framework to explain the divergence between execution completion and bedside substitution.

The study adopts an embedded single-center case study design in a large provincial tertiary public hospital in China. To clarify the boundary of inference, the case was selected for its early and continuous VBP implementation, complete time-stamped governance records, and cross-category variation in consumables. The analysis uses institutional and processual materials, including implementation meeting minutes, cross-departmental coordination records, governance notices, and an execution-tracking ledger covering 37 centralized procurement batches from March 2025 to January 2026. The study aims at analytical rather than statistical generalization.

Procurement directives can be rapidly translated into auditable organizational execution routines, primarily through quota setting, volume-reporting chain construction, and periodic monitoring. By contrast, clinical substitution follows a different accountability logic: outcome responsibility remains borne mainly by frontline clinicians, and product use must remain professionally defensible, particularly in the context of adverse-event review. The study documents three recurrent pathway patterns observed in this case: routine absorption when no major equivalence or workflow exception is recorded; selective adaptation when workflow fit or risk perception remains contested; and temporary suspension (bounded risk retreat) when documented usability or equivalence problems persist across cycles, thereby constraining the substitution process.

The so-called implementation gap is better understood as a governance effect: a structural separation between measurable execution completion and clinical accountability. The governance absorption framework specifies the conditions under which implementation proceeds through routine absorption, selective adaptation, or bounded risk retreat. Achieving sustainable practice change requires completion-oriented goals to be coupled with controversy-closure procedures, shared responsibility arrangements, transition-period support, and dual-track evaluation indicators.