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The foundational layer of institutional conditions that must function for governance decisions to translate into action and risk responses to remain coherent. The operating substrate is what IOA governs—not the decisions themselves or the events that occur, but the conditions under which institutional action takes place.
A hospital's operating substrate includes: how clinical disagreements are resolved, how new evidence reaches practice, how commitments to patients are maintained across shift changes, and how emergencies escalate through appropriate channels. When this substrate degrades, excellent governance and risk management cannot compensate.
Section 1: The Problem