The article is about strategic management in hospitals, its development was based on the approach of the Strategy as Practice. Its objective was to analyze the process of formation of strategy in the practice of the philanthropic hospital researched. For this purpose, the players involved, how organizational practices influence the formation of strategies and the related praxis were identified. It also studied the position of the institution in relation to its environment, i.e. whether it tends to be voluntarist or deterministic. It is an applied scientific research, characterized as a case study; the data analysis was qualitative and was guided by critical discourse analysis. The results show that the strategies of the institution are not separated from its organizational practices, but that each is influenced by the other. This provides a systemic view, focused on actions, and enables the goals set to be reached. This paper contributes to a better understanding of the strategic process in dynamic, highly regulated environments, showing that although there is environmental determinism, the organization adopts a dialectic perspective, with space for strategic choices. It also contributes with a reflection about the actors involved in the strategic process, as it shows that some actors have no interest in participating in building a formal plan.