When accounting becomes material: managing resource scarcity and patient flow in healthcare organizations

Purpose The purpose is to analyze the performative role of accounting in shaping organizational arrangements around resource scarcity and patient flow in healthcare organizations. Design/methodology/approach A qualitative case study was conducted at an emergency unit (emergency room) in a Swedish hospital. The study draws on interviews, accounting reports, budgets, operating plans and newspaper articles collected between 2020 and 2025 to examine the performative role of accounting in addressing resource scarcity and coordinating financial control and patient flow. Findings The study illustrates how accounting practices make crowding and resource scarcity visible, actionable and negotiable across organizational boundaries. The findings show how accounting contributes to redistributing accountability, reframing crowding as a system-wide organizational problem and enabling temporary organizational arrangements aimed at improving patient flow and managing resource scarcity. Originality/value This study contributes empirically by illustrating how accounting not only creates tensions between financial control and patient flow but also becomes mobilized by managers to make problems visible and to negotiate the redistribution of scarce resources. It therefore shows how accounting has become integrated in healthcare operations and professional work in established New Public Management settings. Conceptually, the study specifies the performative role of accounting through three interrelated dimensions: the constitution of crowding as a system-wide organizational problem, the redistribution of accountability across organizational boundaries and the materialization of temporary organizational arrangements as a response to system-wide problems.