What Is an ‘Institution’? A Hospital, for Example

Abstract. St Bartholomew's Hospital has kept its name and site since 1123 through changes so complete that almost nothing done there today resembles what was done at its founding, while emergency hospitals in 1918 and 2020 acquired an institutional identity within days. This article uses the contrast to ask what the word "institution" accomplishes analytically. Drawing on Living Value Theory, it argues that the primary phenomenon is living coordination, sustained through five irreducible mediations, five levels of recursivity and three types of recursive counterpart. An institution is the symbolic stabilization through which a configuration of that coordination becomes recognizable as an enduring form. The article distinguishes institutionalized coordination, institutional identity and organizational identity, so that marriage and money count as institutions without having to be sued, funded or merged as an NHS trust can. This revises the earlier definition of institutions as architectures of recursive compression, which now appears as one major achievement within institutionalized coordination rather than as the institution itself. Institutional inside/outside distinctions are shown to be stabilizations of boundaries that arise through other mediations, and treating them as the edges of living coordination produces the familiar difficulty of reconnecting institutions with their "contexts." Vital stakes, rather than institutional classifications, determine how far inquiry must follow the processes involved. Historical cases make the argument concrete: tuberculosis sanatoria and the 1959 Madras trial of home treatment, the modernization and closure of asylums, the 1918 influenza wards and the NHS Nightingale. Together they distinguish designation, capability and deployment, and they show that what endures under one institutional name is a changing achievement of living coordination whose components differ in speed and reversibility. Against calls to imagine hospitals otherwise, the article concludes that hospitals have already become otherwise many times, and that explaining why must come before prescribing what they should become.

I. The Hospital That Is Never the Same Hospital

St Bartholomew’s Hospital has stood on the same ground at Smithfield, just outside the old walls of the City of London, since 1123, when Rahere, a former courtier of Henry I, founded a priory and a hospital there for the sick poor. For more than nine hundred years people have spoken of it as one hospital. Over those nine centuries nearly everything that happens under its name has changed: its patients and staff, its medical practices and technologies, its professional hierarchies, its buildings and the layout of its wards, the ways in which it is financed, the diagnostic categories it uses, and its relations with households, parishes, the City and the state. When the priory was closed in 1539 the hospital survived without an income; in 1546 Henry VIII granted it to the City of London, and in 1547 he endowed it with property. It became a great voluntary hospital, acquired a medical college in the nineteenth century, entered the National Health Service in 1948 and now forms part of a much larger NHS trust running several hospitals across east London. Almost nothing that was done within it in the twelfth century is done there today, and almost nothing done there today could have been imagined by its founder. Its own history nevertheless claims continuous patient care on the same site for longer than any other hospital in England, a claim that holds across the most drastic changes in its constitutional form (Barts Health NHS Trust n.d.). In ordinary speech, in law and in its own histories, it remains the same hospital.

The old philosophical form of this puzzle is the ship of Theseus, whose planks were replaced one by one until none of the original timber remained. The hospital is a harder case, because what is replaced over its history is not only material. Its purposes, its ways of treating illness, the kinds of people it admits and the authority under which it acts have all been transformed. What, then, makes the claim of sameness possible? The name, the site, the legal organization, a continuity of care, an accumulation of professional practice and public recognition may each contribute to continuity, yet none of them identifies a single substance that has persisted unchanged. Whatever identity the hospital possesses persists through processes that never stop changing.

The converse puzzle is a hospital that exists for only a few weeks. On 2 October 1918, as influenza spread through Philadelphia, H. C. Wood Jr, professor of pharmacology at the University of Pennsylvania, requested that an emergency influenza hospital be established on campus, and two days later the Hospital of the University of Pennsylvania was placed under quarantine. Two fraternity houses, Delta Psi and Phi Kappa Psi, which had been earmarked as barracks for a naval training unit, were fitted out as wards. By 10 October the emergency hospital was treating twenty-nine students. On 19 October the last patients were discharged or transferred to the University Hospital, and on 22 October the houses were handed over as barracks after all (University of Pennsylvania Archives 2018). In little more than a fortnight, the same buildings had passed through three institutional identities.

In 2020 the NHS Nightingale Hospital London was formally opened on 3 April in the ExCeL exhibition centre in London’s Docklands, after a construction programme of nine days. It had been planned for up to four thousand beds, of which only about five hundred were completed (Hopkirk 2021), and it received its first patients on 7 April. During the first wave of the pandemic it admitted fifty-four critically ill patients, whose mortality and need for organ support were comparable to those of patients in established intensive care units. Fewer came than had been forecast, because lockdown slowed transmission and existing hospitals expanded their own critical care capacity, and after about two months the hospital was placed on standby (Collins et al. 2021). The Nightingale was therefore a clinically capable hospital built against a future that, in the form most feared, did not arrive.

What made these sites hospitals? Neither had to accumulate an institutional history within its own walls, because clinical knowledge, trained personnel, equipment, administrative systems and legal authorizations that already existed elsewhere could be brought together quickly. The two cases nevertheless differ instructively. The Philadelphia wards answered a present demand for beds, whereas the Nightingale was contingency capacity against an anticipated catastrophe. In both, three things that ordinary speech runs together came apart: official designation as a hospital, the clinical capability to function as one, and the actual deployment of that capability. The opening paradox can therefore be stated precisely: a hospital may remain identifiable through extraordinary transformation, while another may acquire its identity almost overnight, and the designation, the capability and the use of such a hospital may follow quite different courses.

The question here is not whether hospitals are institutions, which under every ordinary classification they obviously are, but what the word institution accomplishes analytically. Ordinary usage slides between three things: the stabilized forms of living coordination that make hospital care repeatable, the hospital as an enduring institutional form, and a particular named organization such as St Bartholomew’s. The thesis of this article is that an institution is an L4 symbolic stabilization through which a configuration of living coordination becomes recognizable as an enduring form, that an organization is a narrower L4 stabilization of a particular identity within such a form, and that the stability of neither may be confused with the changing processes they designate. The hospital will serve to show why these distinctions matter for ontology, for ethnography, for institutional history and for the explanation of change.

II. The Ontological Mistake: Mistaking Institutions for What Exists

Classical sociology and much contemporary anthropology speak of institutions as entities that have properties, perform actions, maintain boundaries and undergo change. We say that the hospital admitted the patient, that the hospital adopted a new treatment, that the hospital failed its patients, that the hospital resisted reform and that the hospital closed. Such expressions are practical and often indispensable. Each condenses a vast range of heterogeneous coordinations, carried out by many people, materials and organisms over very different stretches of time, into a single grammatical subject. Two influential accounts have taken this condensation seriously. Mary Douglas (1986) made institutions the subject of a verb in the very title of How Institutions Think, arguing that institutions confer identity, classify, remember and forget, and that they secure their legitimacy by grounding their classifications in analogies with nature. John Searle (1995) went further in distinguishing the underlying conditions of an institution from the status imposed upon them. In his formula, X counts as Y in context C: an institutional fact exists by collective recognition, and the status it confers carries rights, obligations and powers that X could not possess by virtue of its physical features alone. His examples include money, property, marriage and government.

Read quickly, the present argument might look like a variant of Searle’s, in which a configuration counts as a hospital when it acquires an institutionally recognized status. The difference lies in what each account takes the underlying reality to be and in how it treats time. For Searle, the X term is specified through physical facts, collective intentionality and constitutive rules, and the analysis asks what makes institutional facts possible at all. Neither he nor Douglas offers a differentiated and historically dynamic ontology of the living coordination that institutional stabilizations identify. Such an ontology must specify the mediations, recursivity levels and counterpart types through which that coordination is sustained; it must show how institutional distinctions persist while the configurations beneath them change; and it must explain why the temporalities of those configurations diverge from the temporality of the institutional identity. The third task is the decisive one, because it brings historical transformation into the ontology itself, where accounts of institutional facts have largely treated it as something that happens to institutions once they are constituted. The risk in all accounts that begin from the institutional fact is that a useful symbolic compression becomes an ontological premise. The analyst then begins with the institution and investigates its internal workings, its culture, its politics and its relations with an environment, instead of asking which living coordinations make the designation meaningful in the first place.

Living Value Theory starts elsewhere. Living beings continuously coordinate their lives through five irreducible mediations: multisensorial embodiment, multispecies being-with, multiversal dwelling, multimateriality and multisymbolization. They do so within mesocosms, historically constituted worlds of living possibility, practical involvement, material arrangement, environmental condition, symbolic articulation and vital stakes (Ecks 2026a). These coordinations do not become intelligible because they belong to institutions that already exist. Institutions become identifiable because particular configurations within these coordinations are symbolically identified and stabilized. The order of explanation must therefore be reversed: living coordination does not occur because an institution first exists, and institutions become recognizable through living coordination that has been identified and stabilized as such. This is a claim about ontological priority. It does not deny that institutional definitions, once established, act back upon and reshape the very coordinations they identify.

Within living coordination so understood, three analytical objects must be kept apart. Institutionalized coordination is living coordination that has become stabilized and repeatable across many situations, as in marriage, property, money, medical practice or the education of the young; it is sustained through all five mediations and is never reducible to its symbolic articulation. An institutional identity is the L4 stabilization through which such coordination becomes recognizable as an enduring form: marriage as such, money as such, the hospital as a kind of place where the sick are cared for. An organizational identity is a narrower L4 stabilization within such a form, capable of sustaining continuing attributions of membership, jurisdiction, authority, resources, obligations and history, as St Bartholomew’s Hospital, an NHS trust or a particular university does. These are nested possibilities rather than further mediations or separate kinds of substance, and many institutional forms exist without any organization corresponding to them. Marriage cannot be sued or merged, and neither can money, yet both coordinate living processes across immense populations and long historical periods. The word hospital moves between the second and the third, naming sometimes an institutional form and sometimes a particular organization. St Bartholomew’s is best described as a historically identifiable organization within a much wider institutionalization of hospital medicine, and the argument that follows applies to institutional and organizational identities alike: neither should be confused with the living coordination it designates.

The decisive level is L4. In the account of recursivity used here, the fourth level is where symbolic articulation becomes socially sustained and institutionally consequential reflexivity. A question raised at L3, such as whether a converted fraternity house is now a hospital, reaches L4 only when its answer is stabilized beyond the conversation in which it was asked. A hospital is therefore more than a name used at L3. Its identity is stabilized across many sites and people at once: in statutes and regulations, organizational charts and financial accounts, registers and classifications, professional authorizations, official histories and public expectations. This is why a hospital can be recognized as the hospital by people who have never entered it, and why, as an organization, it can appear in government statistics, own property, receive funding, employ staff and be inspected. None of these achievements requires the coordination beneath the designation to stop changing. On the contrary, an L4 identity often makes it possible to coordinate continuing change under a stable designation, so that a ward can be rebuilt, its nurses retrained and its catchment redrawn while the hospital remains, for every legal and administrative purpose, the same body.

The institution is therefore real, but its reality is derivative. A legal designation as a hospital can authorize the administration of treatment, mobilize public money, impose professional obligations and determine where ambulances take patients. These consequences arise because multisymbolic stabilization is enacted together with embodiment, being-with, multimateriality and dwelling, never because the symbol acts by itself. An authorization that no trained body takes up, in a building without oxygen, in the depth of a winter surge of respiratory illness, authorizes very little. The symbolic category cannot replace its mesocosmic realization. An institution is accordingly neither a fiction nor a mere social construction, and the illusion to be dispelled lies elsewhere, in the assumption that institutional identity transparently describes a bounded, continuous and self-contained object.

These distinctions require a correction of the account of institutions as recursive compression. That account defined a social institution as a mesocosmic stabilization architecture that compresses interrecursive unpredictability into durable, repeatable coordination appearing, from outside, as if it were nonrecursive, and it identified institutional reality with that architecture (Ecks 2026e). It correctly identified a central achievement: dependable coordination among beings whose responsiveness to one another can never be fully predicted. Its definition nevertheless treated the institution as an architecture operating upon an otherwise independent field of living coordination, whereas recursive compression is itself an accomplishment of living coordination. Moreover, many of the coordinations that matter most in a hospital are not primarily attempts to compress interrecursivity at all. Oxygenation, wound healing, sterilization, the action of a drug, a patient’s sleep, the transmission of infection, the imaging of a lung and the maintenance of an electrical supply involve counterparts of different kinds, many of them nonrecursive or selfrecursive. The present argument is therefore a revision of the earlier definition rather than an elaboration of it. What that definition described is a major achievement of institutionalized coordination, located within the wider mesocosmic configuration, while the institution as such is the L4 stabilization through which that configuration becomes identifiable as an enduring form. The two formulations answer different questions, and only the second answers the question of what an institution is.

Two kinds of stabilization must accordingly be distinguished. Mesocosmic stabilization, which produces institutionalized coordination, comprises the embodied, relational, environmental, material and symbolic processes that make particular coordinations repeatable. L4 institutional stabilization is the reflexively sustained symbolic identification of some of those coordinations as an enduring form, and organizational stabilization adds a particular identity with its own history, membership, purpose and boundary. The two kinds interlock without being identical. A hospital can remain officially recognized long after important clinical coordinations have moved elsewhere, and hospital-like care can be coordinated without any separately recognized hospital, as when a home becomes the site of dialysis or of post-transplant care (Heinemann 2015; Seo 2025).

III. Living Coordination Across the Five Mediations, Five Levels and Three Counterparts

Consider an ordinary admission. An older man living with his wife on the edge of a Scottish town becomes breathless over several days in January. His wife notices that he is slower on the stairs and no longer finishes his meals, while he insists that it is only a cold. A telephone consultation with a general practitioner leads to a home visit, an examination, a reading of oxygen saturation and a call for an ambulance. The road is icy, and the ambulance takes longer than it should. In the emergency department he is assessed, a chest X-ray is taken, blood is drawn and sent to the laboratory, oxygen and intravenous antibiotics are started, and he is admitted to a medical ward. Five days later he goes home with a course of tablets, a follow-up appointment and a daughter who has arranged to stay for a week. Nothing in this sequence is unusual. The task is to reconstruct what is being coordinated without first locating each event within a department, an institution or a professional role. Read in this way, the coordination plainly extends beyond any formal hospital boundary, beginning in a kitchen and ending there.

Each of the five mediations is at work throughout. Multisensorial embodiment includes the breathlessness, fever, fatigue and reduced mobility of the patient, and equally the trained hands, eyes and ears of the clinicians who examine him, among them the nurse who recognizes a particular grey pallor before any number confirms it. Multispecies being-with includes his wife’s watchfulness, the general practitioner’s attention, the paramedic’s reassurance, the work of nursing teams and the daughter’s arrival, but also the bacteria in his lungs and the organisms circulating on the ward, living counterparts with which every act of care must reckon. Being-with is far broader than the formal roles an institution recognizes. Multiversal dwelling comprises the conditions that no one made: the winter season in which respiratory infections surge, cold and ice, the early darkness of January afternoons, the distance and terrain between his house and the nearest emergency department, and the air he breathes. Multimateriality comprises everything that was made, from the house and the ambulance to the hospital buildings and their ventilation, the beds, drugs, cannulas, piped oxygen, X-ray equipment, laboratory analysers, records and protective clothing, and the electrical grid with its back-up generators. Multisymbolization runs from his own claim that it is only a cold through the referral letter, the diagnosis of pneumonia, the early warning score, consent, guidelines, professional categories and budgets to legal authority and the name of the hospital itself. The mesocosm in which each of these events occurs is constituted through all five mediations, although no isolated event need display all five as immediate and equally identifiable determinants. Distinguishing them serves to prevent any one mediation from being mistaken for the whole, which is the characteristic error of disciplines organized around a single mediation, and the mediations should never be read as five boxes into which experience is sorted.

The same trajectory can be read through the five levels of recursivity, which describe how particular activities become recursively available to those engaged in them.

Table 1. Levels of recursivity in one patient’s trajectory

The same episode moves between these levels. A nurse may take an observation through absorbed expertise, notice an unusual sign, raise a question with a colleague, initiate a formal escalation and later challenge the adequacy of the escalation protocol itself. The level at which a coordination becomes available is not fixed by institutional location or professional status, and the levels are not gradations of critical intensity. When the man’s wife asks why he had to wait so long for an ambulance, her question is an L3 question; if she pursues it through a formal complaint and the ambulance service investigates, it becomes an L4 matter. It reaches L5 only if someone, perhaps the wife herself, perhaps a paramedic or a health planner, begins to question the assumptions by which the service classifies calls, distributes risk between rural and urban populations and defines the limits of its own responsibility. What distinguishes the levels is the kind of recursive opening or repositioning achieved, never the vehemence with which a question is asked. A consultant, likewise, may spend much of a ward round at L1. Nor does change have to originate at L4 or above. A deterioration in breathing felt at L2, or the failure of an oxygen supply, can force a reorganization of higher-level arrangements that no symbolic deliberation initiated.

A hospital is also far more than an arena of human interaction, and the three types of recursive counterpart make this explicit. Nonrecursive counterparts include the oxygen supply, the X-ray machine, the record, the architecture and the drug as a substance. Many of them are far from inert. A ventilator adjusts its delivery to the pressures it detects, an infusion pump alarms when its line is occluded, and a ward’s heating responds to its thermostat. Such state-dependent adjustment remains a nonrecursive material process, because what is adjusted, and within what limits, was specified in the design, and nothing in the machine has a stake in its own continuation. Nonrecursive never means stable or predictable either: a generator that fails during a storm is nonrecursive, and so is a contaminated batch of medication. Selfrecursive counterparts are living organizations that alter in relation to their own ongoing state as they continue living: the patient’s body as it responds to infection, the clinician’s attention as it frays across a twelve-hour shift, a bacterium altering its own activity under antibiotic stress. The analytical level matters here. The emergence of antibiotic resistance across bacterial populations is an evolutionary process of selection over many generations, distinct from the selfrecursive responsiveness of any individual organism, and the two bear on a hospital’s multispecies being-with at different scales and over different spans of time. Interrecursive counterparts orient to one another’s responsiveness: patient and nurse, nurse and doctor, husband and wife, and doctor and family in a difficult conversation about whether to escalate treatment. Interrecursivity is one particular form of being-with rather than its synonym. Much care proceeds without intensive reciprocal interpretation, and many of the most consequential constraints on care involve no one responding to the patient at all. A locked door, an unavailable medicine, a delayed laboratory result or a failing generator can transform care without being an interrecursive partner.

The implication is that an ethnography of a hospital requires an ontology adequate to all five mediations, all five levels and all three counterpart types. These are dimensions of analysis rather than seventy-five institutional compartments. Different combinations become consequential at different moments, and no single clinical encounter needs to display every combination in an equally developed or observable form. The institutional label “hospital” does not specify in advance which of these coordinations matter, how they relate, what their vital stakes are or how they change. Only empirical reconstruction can establish that.

Recursive compression has its place within this account. Protocols, classifications, trained dispositions, material arrangements and professional expectations make much hospital activity predictable and reduce the need for continuous interrecursive negotiation. An early warning score allows a junior nurse to escalate care without first having to persuade a sceptical doctor, because the score has already settled what counts as sufficient grounds. This achievement is real and essential, but it is inseparable from the wider coordination. The recovery of the man on the medical ward, the maintenance of a sterile field or the availability of oxygen at three in the morning cannot be explained by compression alone. Recursive compression is an important pattern within living coordination and never a substitute for its full ontology.

IV. L4 Stabilization and the Making of Institutional Boundaries

There is never just one L4 stabilization. To define something as a hospital entails a vast range of further symbolic stabilizations: what counts as a patient, an admission, a treatment, a discharge or a bed; which people count as hospital staff and which do not; which spaces belong to the institution; what counts as clinical responsibility; which treatments are authorized; which activities are financially attributable to it; and which events count as its successes, failures or harms. These stabilizations reinforce one another. The category becomes more solid as innumerable other L4 designations make it administratively, legally, professionally and publicly actionable, until it begins to appear as a self-contained object.

This raises a question that any adequate account must answer. Not every L4 stabilization is an institution. The diagnosis of pneumonia, the norm of hand hygiene and the protocol for escalating suspected sepsis are all L4 stabilizations, yet nobody calls them institutions. If institution were merely another name for L4 coordination, the concept would apply to everything and explain the specificity of nothing, which is precisely the weakness of vaguer concepts such as entanglement. The distinctions drawn above help here. An institutional identity stabilizes a whole configuration of coordination as an enduring form within which many other stabilizations, including diagnoses, norms and protocols, find their place; hand hygiene is a norm of hospital medicine, whereas hospital medicine is no norm of hand hygiene. An organizational identity adds a further and more specific capacity, since it can carry a continuing series of attributions while the people and activities associated with it change. St Bartholomew’s can be held responsible, sued, funded, inspected, merged and commemorated, whereas neither a protocol nor hospital medicine as such can be any of these things. These capacities belong to organizations and should not be made the definition of institutions in general, or marriage and money would cease to count as institutions at all. Both distinctions are offered as propositions to be developed rather than as checklists of formal properties. The question they pose is what makes certain symbolic stabilizations function as enduring forms, and certain others as particular identities to which further stabilizations attach.

Where does a hospital begin and end? At its front door, at the edge of its property, at the limit of its employment contracts, at the reach of its clinical responsibility, at the point where its budget ceases to apply, or at the boundary of the health board’s jurisdiction? These boundaries do not coincide, and a hospital’s legal, spatial, organizational, financial, professional and clinical edges can differ considerably. None of them introduces distinction into an otherwise undifferentiated world. Living beings distinguish inside from outside long before L4 becomes possible, through skin and membrane, burrow and territory, the threshold of a doorway and the felt difference between a warm kitchen and an icy road, and a family can speak at L3 of taking someone into hospital without stabilizing anything at all. What an L4 stabilization adds is that a particular distinction becomes an either/or that is enduring, shareable, actionable and consequential across many situations: admitted or not admitted, staff or contractor, authorized visitor or intruder, inside or outside the budget. Institutional inside/outside distinctions are therefore L4 stabilizations of particular boundaries. They draw upon spatial, embodied, material and practical distinctions that arise through other mediations, but they neither originate those distinctions nor reproduce the actual extent of the living coordinations they classify. Different distinctions become consequential for different purposes, and none of them defines the totality of what a hospital coordinates.

Consider a cleaner employed by an external contractor who works every day on the same ward. Materially and practically, her work is integral to infection control: what she wipes, how often and in what order shapes the multispecies being-with of patients and microbes as surely as any prescribing decision. Organizationally and financially she belongs to another company, appears on no ward staffing return and answers to a different manager. Karen Messing (1998) showed that hospital cleaners hold detailed knowledge of disease prevention that their position in the hierarchy renders invisible, and Zaman and van der Geest (2020) have described ward boys, cleaners and gatemen in a Bangladeshi hospital as brokers without whom care would not circulate. The institutional distinction fails to reveal the full character of this coordination and partly conceals it.

A hospital is, moreover, almost never a stand-alone organization. A Scottish hospital exists within a territorial health board, which exists within NHS Scotland, which depends in turn on professional regulators, universities and medical schools, suppliers, public finance, legislation and government directorates. Within the hospital, departments, specialties, clinics, committees and services each carry L4 stabilizations of their own. Far from forming cleanly nested natural kinds, these identities overlap, intersect and partly contradict one another. A single clinician may simultaneously be an employee of the health board, a registrant of the General Medical Council, an honorary university researcher, a member of a specialist team and an implementer of national guidelines, and the same activity can be categorized differently under each of these stabilizations.

Here lies the central difficulty. Once the analyst accepts the L4 institutional boundary as the starting point, a distinction that was originally an achievement of symbolic coordination becomes the organizing principle of empirical inquiry. Processes that cross the boundary are then described as connections between separate entities: hospital and community, hospital and family, hospital and state, hospital and pharmaceutical industry, hospital and environment. The analyst must subsequently try to reconnect what the classification has already separated. Yet the man’s illness, his wife’s watchfulness, the manufacture of his antibiotics, the training of the nurse who escalated his care and the electricity that powered the X-ray were never isolated processes awaiting connection. The difficulty of reconnecting the inside and outside of institutions is in large part produced by mistaking institutional inside/outside distinctions for the boundaries of living coordination. This is more than a methodological inconvenience, because it can systematically misidentify what needs explaining.

Much contemporary anthropology responds to the inadequacy of institutional boundaries by declaring institutions entangled with their communities, environments, histories and politics. Kehr and Chabrol’s (2026) review of hospital anthropology is exemplary in this respect. It traces a scholarly trajectory from hospitals as refractions of local culture, through political and economic terrains and haunted infrastructures, to more-than-human environments and more-than-disciplined sites, and it repeatedly affirms that hospitals are not islands cut off from wider society. Solomon’s (2022) account of the traffic through a Mumbai trauma ward goes further, showing the contours of the hospital dissolving into the city around it. These observations are accurate. Entanglement, however, is often only a verbal acknowledgment that the original boundaries do not hold, one that leaves the prior institutional units intact and then announces that they are connected. The more fundamental move is to stop beginning with presumed institutional separateness and adding connections afterwards, and instead to begin with living coordinations and investigate how institutional separateness comes to be symbolically stabilized and practically enacted. This reversal is at once ontological and methodological.

A sceptical reader may object that once the hospital boundary is refused, nothing stops the inquiry. If the household, the ambulance service, the pharmaceutical supplier and the electricity grid belong to the field, why not the whole global economy? To answer that everything belongs to the same mesocosmic coordination would make the empirical object indefinitely expansive. The principle of selection is vital stakes. The field is reconstructed through the coordinations consequential for the vital stakes under investigation, including those that are absent, obstructed, prevented or difficult to articulate. For a study of how a man recovers from pneumonia, the relevant field includes domestic care, transport, clinical decisions, drugs, oxygen and the material conditions of convalescence at home. For a study of hospital staffing, different coordinations become consequential, among them rotas, training pipelines, the international migration of nurses, housing costs near the hospital and the sleep of night-shift workers. For a study of a hospital closure, the field may extend through public finance, urban planning, political accountability and the treatment arrangements that replace the hospital or fail to. Such a field has edges, but they are drawn by the processes being explained rather than by the classifications of the institution under study, which makes the selection empirically justified rather than arbitrary. Rejecting institutional boundaries as ontological givens therefore does not commit ethnography to studying everything.

V. How Hospitals Came into Being, Changed and Disappeared

Projecting the contemporary acute hospital backwards produces a single institution with a long pedigree. The historical record shows something else. Institutions offering shelter, charity, nursing, isolation, medical treatment, surgery and religious care have all been called hospitals, and they did not organize the same activities. In Britain before 1948, voluntary hospitals funded by subscription and charity, Poor Law infirmaries, municipal hospitals, fever and isolation hospitals, county asylums, specialist hospitals for eyes or for children, sanatoria and cottage hospitals coexisted, each with its own patients, finances and forms of authority (Abel-Smith 1964; Cherry 1996). The great London voluntary hospitals multiplied in the eighteenth century, specialist foundations proliferated in the nineteenth, and the cottage hospital movement spread from the opening of the first such hospital at Cranleigh in Surrey in 1859 into a dense network of small institutions run by local general practitioners (Granshaw and Porter 1989; Cherry 1996). Rather than emerging once and then developing as one institution, many forms of hospital coordination emerged under different circumstances, and the same word retrospectively gathers together configurations with strikingly different vital stakes.

Each of these forms can be reconstructed as a confluence of historically available capacities and stakes: population concentration, transport, surgical technique, medical training, charitable and later public finance, the control of infectious disease, diagnostic equipment, professional specialization and public expectation. None should be elevated into a master cause. A cottage hospital within reach of a cart from the surrounding villages addressed different problems through different coordinations than a metropolitan teaching hospital organized around clinical instruction. Some new hospitals emerged because existing facilities could not or would not pursue particular stakes; the frequent refusal of voluntary hospitals to admit infectious, chronic and incurable cases left those patients to the infirmaries and fever hospitals (Abel-Smith 1964). What became compelling under specific conditions was not necessarily what was ideologically celebrated. Hospital formation can follow pressures that are primarily clinical, epidemiological, material, environmental, financial or political, and none of these can be reduced to changes in multisymbolic representations of healthcare.

The tuberculosis sanatorium offers the clearest case of a specialized hospital form that was assembled, transformed and largely dissolved within a single century. Sanatoria brought together a distinctive configuration: geographic separation, often on rural or upland sites chosen for their air and light; prolonged rest alternating with graduated exercise and labour; a rich diet; open verandas and wards designed for ventilation; closely supervised daily routines; and residence lasting months or years. Their therapeutic rationale gave unusual weight to multiversal dwelling, recruiting climate, altitude, fresh air and sunlight into care, and to the disciplined embodiment of patients whose days were regulated hour by hour, while depending as much as any hospital on buildings, food supply, nursing and record-keeping. The sanatorium responded at once to suffering, to the fear of transmission, to medical uncertainty and to the limited therapeutic possibilities of the time. Linda Bryder’s (1988) social history of tuberculosis in twentieth-century Britain shows how varied these arrangements were in practice: local schemes differed widely, sanatoria served purposes of segregation and moral training as well as treatment, and their clinical results were contested long before effective drugs arrived.

Chemotherapy changed what could be accomplished without lengthy residence. The Medical Research Council’s (1948) randomized trial of streptomycin was followed during the 1950s by combination regimens with para-aminosalicylic acid and isoniazid. The most telling demonstration of what this meant for the institutional configuration came from South India. In Madras, the Tuberculosis Chemotherapy Centre randomly allocated patients to treatment at home or in a sanatorium and found that home treatment with chemotherapy, supported by a domiciliary service that supervised patients and checked that they were taking their drugs, achieved results close to those of the sanatorium, even though the home-treated patients had poorer diets, more crowded housing and less rest (Tuberculosis Chemotherapy Centre, Madras 1959). The study tested directly whether a therapeutic stake still depended on a particular institutionalized configuration of care, and it found that it no longer did to the same degree. Diet, housing and rest had been the sanatorium’s own therapeutic means. It would be misleading, however, to say that the drugs moved treatment out of one mediation and into others, as if mediations could substitute for one another. Treatment at home still depended on dwelling and on the household’s living conditions, and the sanatorium had always depended on materials and bodies. What changed was the configuration and relative significance of particular coordinations within all five mediations, above all the clinical value of prolonged residence. The change also generated new burdens. Households took on daily care and much of the work of watching over a patient for a year or more; clinics and visiting services had to supervise treatment across scattered homes; supply chains had to deliver drugs reliably and without interruption; and adherence to a long course of daily tablets, once secured by the sanatorium’s routine, had to be sustained by other means. Sanatoria declined, and much tuberculosis care migrated to chest clinics, general hospitals and supervised outpatient treatment. The history of tuberculosis control nevertheless cautions against telling this as a simple story of drugs emptying sanatoria, since the timing and manner of their closure depended on local finance, staffing and policy (Bryder 1988).

Nor did the sanatorium disappear in every respect. Some buildings were turned into general or psychiatric hospitals, some services moved, and clinical expertise continued in chest medicine. When a tuberculosis hospital closed, what exactly ceased to exist? Its name, its legal entity, its residence-based treatment, its configuration of personnel, its patient population or the coordination of tuberculosis care? These are different questions with different answers, and the single statement that the sanatorium closed conceals them all.

The history of psychiatric institutions shows redistribution as much as disappearance. The nineteenth-century county asylum assembled large rural estates, farms, laundries, chapels and resident staff into self-contained communities that Goffman (1961) would later treat as paradigm cases of the total institution, perhaps the most tightly bounded image of an institution that social science has produced. In 1961 the Minister of Health, Enoch Powell, told the National Association for Mental Health that the great asylums would be run down, and the Hospital Plan of the following year envisaged psychiatric units within district general hospitals (Ministry of Health 1962). The categories themselves changed. Psychiatric units came to exist inside general hospitals, general hospitals had long held psychiatric patients of various kinds, and community services, outpatient clinics, day hospitals and specialist inpatient units came to coexist. The causes were contested, with new medications, therapeutic optimism, civil-liberties critiques and the fiscal attractions of closing expensive estates each given priority by different historians (Scull 1977). Since boundaries between institutional types of hospital do not identify discrete, enduring configurations of living coordination, what needs investigating is the redistribution of particular therapeutic functions, professional practices, material capacities and arrangements of care. The closure of an asylum need not mean the disappearance of inpatient psychiatric treatment, and deinstitutionalization did not guarantee better lives for everyone it discharged (Barham 1992). A differentiated account must investigate both the coordinations preserved and those lost.

Pandemic hospitals show emergence and disappearance at extraordinary speed. In Philadelphia in October 1918, as existing hospitals were overwhelmed, emergency facilities were opened in schools, parish houses and disused buildings. One of them occupied the salvaged building of the old Medico-Chirurgical College, where medical students assembled the beds themselves on wards of about twenty-five beds each, and it closed on 16 November (Starr 1976). Alongside it ran the short life of the Penn fraternity houses. These facilities answered a present and visible demand. During COVID-19, emergency hospitals were again assembled from existing infrastructure, but many were built as contingency capacity against a feared escalation, so that their use depended on how that future unfolded. Some admitted patients and achieved outcomes comparable to established units, as the London Nightingale did, while others were barely used. In Madrid, Kehr (2021) has described a pandemic hospital in which care was as much staged for the public as delivered to patients.

These cases yield three propositions. First, rapid hospital emergence depends on capacities accumulated over much longer histories, since the trained bodies, the drugs, the equipment and the authority to admit patients all had to exist before any of them could be gathered into a fraternity house or an exhibition hall. Second, designation, capability and deployment are distinct achievements. A building classified as an emergency hospital is not thereby capable of functioning as a clinically effective one, since staff, oxygen, equipment, transport, referral arrangements and the appropriate configuration of patient care must actually come together; and a capable hospital may still treat few patients, because what it is used for depends on the need that arrives. Third, the history of an emergency hospital can be governed by a future that never happened. The Nightingale was assembled against the possibility of catastrophic shortages in critical care, and its admissions measure the distance between capacity assembled, capacity exercised and capacity ultimately required. To read those figures simply as institutional failure would mistake an anticipatory coordination for a failed one, and would miss how an uncertain future, mixed with a present already under strain, organized the hospital’s entire existence (Ecks 2026b).

Rather than marking stages in a universal history of the hospital, these cases together demonstrate the diversity of possible institutional trajectories. Some hospitals become obsolete in their established form. Others absorb new activities. Some are assembled in days and dismantled in weeks. Others remain identifiable while nearly everything they do changes. The institutional category remains recognizable across transformations that cannot be explained by reference to the category itself, and this is why history makes the ontological problem unavoidable.

VI. Differential Temporalities and the Puzzle of Institutional Continuity

The opening puzzle can now be restated. The temporality of an institutional designation is not the temporality of the living coordination it designates. A hospital’s name may endure for centuries while the embodied capacities of its staff change continuously, its patient population turns over, treatments appear and disappear, supply chains are reorganized, buildings are repaired or replaced, and its authority and funding arrangements are substantially recast. The L4 category stabilizes an identity across these changes. It makes it possible to speak of one institution with one history even when the coordination beneath that identity has been transformed many times over. Institutional continuity is an achievement of symbolic stabilization, and it is no proof of uninterrupted continuity in the processes it designates. The persistence of an institutional identity is also practically useful, because stable designations make contracts, public recognition, funding, accountability and historical memory possible. The argument is therefore not that identity is false but that identity cannot substitute for analysis.

The coordinations a hospital identifies unfold at very different speeds, within as well as across the mediations (Ecks 2026d).

Table 2. Contrasting temporalities within each mediation in hospital coordination

Rather than five institutional clocks, each mediation contains heterogeneous temporalities that interlock with those of the others, and none of them can be reduced to a common clock time. The trajectory of an institution can therefore be inferred neither from any single mediation nor from an average institutional rate of change.

The explanatory task is to specify how a development in one coordination alters the viability of another, which the observation that things change at different speeds does not yet accomplish. Tuberculosis again provides the mechanism. Effective chemotherapy altered what could be achieved without prolonged residence, and in doing so it changed the value of sanatorium buildings, the distribution of nursing labour, the burdens placed on households, the organization of outpatient services and the justification for public expenditure. These transformations were not synchronous. Treatment capabilities changed before hospital estates were repurposed; funding arrangements and allocations of beds persisted after the therapeutic rationale for them had weakened; and the professional practices of chest medicine, case notification and supervised treatment outlived the institutions in which they had been formed. An institutional history should be able to identify such specific relations of lead, lag and persistence between coordinations, which explains far more than the general observation that everything changes at its own pace. The process must still be reconstructed historically in each case, since nothing guarantees that new treatments produce closures.

A second distinction separates the rate of a transformation from its reversibility. An emergency hospital fitted into an exhibition hall can be established in days and dismantled in weeks, because its material arrangements are temporary and its personnel can return to the hospitals they came from. A purpose-built sanatorium on a remote hillside could lose its therapeutic rationale within a decade while remaining costly to maintain and difficult to repurpose, because its multimaterial form had been built around a configuration of care that no longer held. Fast change can be easily reversible, and slow accumulation can make even a rapid loss of rationale hard to undo. Treating rate and reversibility as distinct properties allows institutional inertia to be explained through durable materials, contracts, professional careers and sunk investments, without reducing it to ideological resistance.

Fast institutions can depend on slow historical accumulations. The London Nightingale could be built in nine days because a national health service, a professional workforce, intensive care medicine, ventilator manufacturing, military logistics, an oxygen supply industry and a legal framework for commandeering capacity already existed. In Philadelphia in 1918, an emergency hospital could open within days because a professor of pharmacology, hospital interns and medical students had been trained over many years before the epidemic arrived. The two differed in their relation to future need, for the Philadelphia wards filled as they opened, whereas the Nightingale was built against a future that might or might not arrive. The temporality of assembly differs from the temporalities of the capacities assembled. Conversely, an emergency hospital may close rapidly while those capacities continue elsewhere. Institutional emergence, institutional functioning and institutional persistence have distinct temporalities, because they do not involve exactly the same configurations of living coordination.

It follows that the persistence of an institution cannot be explained merely as resistance to change. Some arrangements endure because their constituent coordinations continue to meet compelling vital stakes. Others endure because past investments, legal obligations, material constraints, professional hierarchies or political power restrict the available alternatives. Likewise, rapid change need not be evidence of a powerful new ideology. Sometimes it reflects the arrival of a new therapeutic capacity, the disappearance of a particular need or the sudden availability of resources, and in other cases political and symbolic transformations are central. Which mediation explains a particular trajectory must be determined from the historical configuration rather than decided in advance. This also prevents the analysis from becoming functionalist, since the persistence of an institution establishes neither that it works well nor that it works well for all who depend on it.

The same caution applies to the symbolic character of institutional identity. That identity is an L4 stabilization, but its persistence cannot be explained by multisymbolization alone. St Bartholomew’s survived the closure of its priory because buildings, a population of sick poor, the interests of the City, the availability of practitioners and a royal grant all continued to support it. Conversely, a recognized identity may disappear while many of the capacities it identified persist, as when a Nightingale is decommissioned and its staff, equipment and expertise return to the hospitals from which they came. The symbolic stabilization identifies the institutional configuration and helps to coordinate it, but it neither contains nor determines the configuration as a whole. This distinction protects the irreducibility of the five mediations, and with it the coherence of the whole ontology.

Stability and change are therefore simultaneous rather than opposed. The traditional question of why institutions resist change is too crude. A hospital may at the same moment preserve its public identity, replace its imaging equipment, reorganize nursing work, adopt new diagnostic procedures, retain an old building and change its patient population. No single state of stability or change can describe this. The relevant questions are what continues, what changes, at what speed, with what degree of reversibility and with which consequences for other coordinations. Framed in this way, the analysis permits a more precise account of recursive opening and blockage. A previously unavailable treatment may become possible, a long-standing professional arrangement may obstruct its implementation, and a previously accepted hospital function may lose its justification. Whether any of these becomes consequential depends on how the relevant coordinations develop.

The central theoretical conclusion can now be stated. The apparent continuity of institutions is produced by L4 stabilizations that sustain recognizable identities across coordinations whose constituent temporalities differ profoundly, and historical investigation shows that what endures under one institutional name is a changing achievement of living coordination rather than a fixed configuration.

VII. Why Institutional Boundaries Obstruct Explanation, and What This Means for Reform

Return once more to the man who became breathless in January. His symptoms developed at home and his wife responded to them; a general practitioner evaluated them and made a referral; an ambulance crew transported him across icy roads; hospital staff investigated and treated him with medicines manufactured on another continent (Ecks 2022) and with oxygen produced and delivered by an industrial supply chain; he went home to a daughter’s care. What portion of this coordination is the hospital? Institutional classifications can answer administrative questions about admission, discharge, jurisdiction and responsibility, but they cannot determine the boundaries of the processes that explain what happened. The statement that the hospital successfully treated him may be a legitimate institutional attribution. The outcome nevertheless depended on his wife’s recognition of his decline, on transport, on a prior consultation, on laboratory services, on pharmaceutical manufacture, on staffing and on subsequent care at home. An ethnography that begins and ends at the hospital’s institutional boundaries can miss important conditions of its apparent success, and the same holds for its failures.

The methodological response is Ontologically Grounded Theory, which derives its primary analytical categories from the ontology of living coordination rather than from the categories of the institutions under study (Ecks 2026c). The researcher follows living coordinations instead of treating institutionally produced documents, accounts and divisions as the primary shape of the empirical world. This includes investigating what was not done, what was avoided, what could not be articulated and which possible transformations never occurred, and asking how those absences were produced. A hospital visit that was never made may be as significant as a documented admission. A treatment never offered may be crucial to understanding a hospital’s clinical possibilities. A proposed reorganization that never happened may reveal constraints more clearly than a reform that succeeded. Institutional records are themselves L4 stabilizations of selected aspects of living coordination. Hospitals generate vast quantities of records about routine and uneventful coordination, from observation charts and drug rounds to staffing rotas, admissions and routine tests, and what they privilege are the events and distinctions their recording systems were designed to recognize: some foreground routine compliance, others adverse events, others financial or administrative activity. What is systematically difficult to retrieve is the range of possibilities that never crossed the threshold of recording, such as a consultation avoided, a question never asked, a treatment never considered or an alternative not pursued. The catastrophe against which the Nightingale was built belongs to the same class, an event that never happened yet organized everything about the hospital’s existence. That such possibilities leave few traces does not make them inconsequential for living coordination. Situated within mesocosmography, the procedure treats the institutional archive as one form of access among others and never as the outline of the field (Ecks 2026f).

The same reasoning bears on calls to imagine hospitals otherwise. Kehr and Chabrol (2026) place their review within Povinelli’s (2014) anthropology of the otherwise, in which every arrangement of existence, however hegemonic, carries the potential of its own disruption, and they close by asking what a hospital centred on care, healing and human dignity would look like. To imagine alternative forms of care is entirely legitimate, and their own review notes that what and where a hospital is cannot simply be presumed. The difficulty is that the programme still takes the hospital as the bounded subject of a becoming, and then imagines what that subject ought to become. The historical evidence provides a stronger starting point. Hospitals have already become otherwise in innumerable ways: from priory to voluntary charity, from sanatorium to chest clinic, from asylum to district general unit, from exhibition hall to intensive care ward and back again. The scientific problem is to explain why some of these transformations occurred and others did not, which requires asking what vital stakes particular arrangements pursued, which mediations sustained them and how the possibilities of living coordination changed.

The aspiration to epistemic justice illustrates the difference between normative aspiration and empirical explanation. A hospital may indeed be changed to give patients greater authority in interpreting their own experience, and such a change may respond to stakes that patients already pursue. Yet neither the desirability nor the practical viability of that change follows from the general claim that hospitals should become sites of epistemic justice. The empirical questions are more demanding. Who is seeking the transformation, and in relation to which experiences? Through which material and professional arrangements would it be realized? How would clinical care change, and which competing stakes would be affected? Why should this particular reform become important to the people whose coordination it would alter?

Institutional reform typically starts with an L4 identity, and usually with an organization, seeking to change its mission, principles, policies, structure or self-image. Such interventions may be consequential, but their effectiveness depends on transformations within the wider mesocosmic coordination. A new hospital policy may leave embodied clinical practice largely untouched, while a technological change may transform care profoundly without any accompanying redefinition of the institution’s public mission. The primary question is therefore not whether a different institution can be described, but whether a proposed transformation can be realized within, and can alter, the coordinations through which people actually pursue their vital stakes. Institutional change cannot be understood solely as change in an institution’s L4 self-description.

The same argument applies well beyond hospitals: to universities, schools, prisons, welfare agencies, bureaucracies and firms, and equally to institutional forms without any organizational body, such as marriage or property. Their L4 definitions are important achievements, but their actual operation continually extends beyond the boundaries those definitions create. The task of institutional ethnography is to reconstruct, rather than to add ever more contextual connections to bounded institutions, the living coordinations through which institutional boundaries themselves become possible, consequential and sometimes misleading.

VIII. Conclusion: From Institutions Back to Living Coordination

It is possible to speak of a hospital that has endured for nine centuries, and equally of one that existed for little more than a fortnight. Neither case establishes that hospitals are fundamentally bounded entities whose transformations take place within a persistent institutional substance. Both become intelligible once the L4 stabilization of institutional forms and organizational identities is distinguished from the living coordination they identify. St Bartholomew’s is a historically identifiable organization within a much wider institutionalization of hospital medicine, and it is never simply identical with its buildings, staff, patients, legal definitions, technologies, professional practices or symbolic purposes, nor is it a collection of separable components subsequently connected through entanglement. It is an identifiable configuration within a continuously changing mesocosm, whose coordination operates through all five mediations, all five levels of recursivity and all three types of recursive counterpart.

Several propositions follow. Living coordination is ontologically prior, and institutional identification is derivative. Institutionalized coordination, institutional identity and organizational identity are nested possibilities: the first is stabilized living coordination, the second its L4 recognition as an enduring form, and the third a narrower L4 identity capable of bearing continuing attributions of membership, jurisdiction, authority, resources, obligations and history. An adequate account of institutional life must reconstruct all five mediations, all five recursivity levels and all three counterpart types without reducing any one to another. Institutional inside/outside distinctions are L4 stabilizations of particular boundaries that draw on distinctions arising through other mediations; they facilitate coordination but can obstruct the explanation of processes that cross them, and it is vital stakes, rather than institutional classifications, that decide how far inquiry must follow those processes. Designation, capability and deployment are distinct achievements. An institutional identity can endure while the configuration it designates changes profoundly. Institutions emerge, function, transform and disappear through processes that share no single temporality and that differ in reversibility as well as in speed. Institutional change must accordingly be explained through historically changing living coordinations, and it cannot be deduced from the availability or attractiveness of alternative institutional imaginaries.

Institutional recognition makes a configuration more durable, actionable and publicly intelligible. It also produces inside/outside distinctions that can obscure how care, suffering, responsibility and therapeutic possibility are actually constituted. The emergence, rapid assembly, long persistence, transformation and disappearance of different hospitals show that institutional identity and living coordination never share one temporality.

Institutions are historically consequential stabilizations within living coordination rather than bounded things that subsequently enter into living relationships, and the very boundaries by which they become identifiable can conceal the processes that constitute, sustain, transform and dissolve them. An institution is an L4 symbolic stabilization through which a historically particular configuration of living coordination becomes identifiable and repeatable as an enduring form, and an organization is a further stabilization through which particular configurations become governable and accountable. These stabilizations are real and consequential, yet the living coordination they identify continually exceeds and transforms them. To understand institutions, inquiry must begin not with institutions themselves but with the changing mesocosms from which their identities emerge.

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