Configuring strategic action: a comparative study of top management teams and the microfoundations of strategy

Purpose This study examines how and why practitioners, practices and praxis (3Ps) become configured differently across contrasting organizational contexts. Through a comparative study of a university hospital and a private hospital, it investigates how organizational and institutional conditions shape practitioner agency, the function of formal and informal practices, the direction of strategic activity and the meanings attached to strategy work in reliability-seeking organizations. Design/methodology/approach We employ a qualitative comparative case-study design, drawing on 57 semi-structured interviews, archival documents and observational data from a state-affiliated university hospital and a privately owned hospital group located in Antalya, Türkiye. Data were analyzed through an abductive process combining inductive within-case thematic analysis with theoretically informed cross-case comparison. Findings Similar committees, reports, informal interactions and analytical tools produced distinct configurations of strategic action because authority, evaluative criteria, temporal pressures and knowledge were organized differently. In the university hospital, layered authority, professional legitimacy and long-tenured knowledge carriers combined custodial agency with institutional sensemaking; operational issues therefore moved upward for formal authorization, producing upward legitimization. In the private hospital, competitive pressure, market-facing knowledge, founder-centered selection authority and performance- and risk-based evaluation combined entrepreneurial agency with emergent sensemaking; strategic initiatives circulated laterally across functional boundaries before centralized approval and operationalization, producing lateral initiation. Research limitations/implications The two-case design supports analytical rather than statistical generalization. The identified configurations and underlying mechanisms provide a theoretically specified basis for comparison across other reliability-sensitive and institutionally contrasting settings. Practical implications Managers should design strategic processes that enable permeability between formal and informal arenas, recognize multiple forms of practitioner agency and treat strategy implementation as an ongoing sensemaking process rather than a linear execution phase. Originality/value This study makes three theoretical contributions. First, it theorizes the Strategy-as-Practice 3Ps as contextually patterned configurations. Second, it identifies upward legitimization and lateral initiation as distinct mechanisms connecting formal and informal strategy work. Third, it explains how decision authority, evaluative criteria, temporal pressures and knowledge distribution generate different combinations of practitioner agency, practice functions and sensemaking.