Reconfiguring Healthcare in Crisis: Relational Mechanisms of Network Resilience in Regional Hospital Systems

Background Organisational resilience in healthcare systems under stress remains poorly understood, particularly in relation to the role of inter-organisational networks. This study investigates how a regional hospital network in Italy responded to the 2009 L’Aquila earthquake, with a focus on the relational mechanisms enabling system-level stability despite the sudden collapse of a key hospital. Methods We analyse complete inter-hospital patient transfer data (N = 33 hospitals) over four time periods (one pre-shock and three post-shock). Using stochastic actor-oriented models (SAOMs), we assess how hospitals reconfigured their patient referral ties and whether relational mechanisms such as reciprocity, transitivity, and cyclicality changed over time. We also incorporate measures of geographical, institutional, organisational, and cognitive proximity. Findings Despite the collapse, the overall healthcare system functionality remained stable overall. Immediately following the shock, hospitals adapted their collaborative structure by relying on generalised and anti-hierarchical exchange patterns—particularly reciprocity and transitivity. Over time, these mechanisms declined, giving way to more hierarchical, stratified referral structures. Geographical and social proximity significantly shaped tie formation, highlighting uneven responses across the network. Interpretation Our findings suggest that relational mechanisms underpinning social capital are critical for healthcare network resilience. In contexts of high uncertainty, collaborative agility and flexible relational structures allow hospital networks to absorb shocks while preserving functionality. These results offer theoretical contributions to resilience, healthcare management, and network theory, and have practical implications for health system design and disaster preparedness.