Living with layers: the governance and regulation of health care quality in an institutionally layered system

Transcription

1 Living with layers: the governance and regulation of health care quality in an institutionally layered system Hester van de Bovenkamp Annemiek Stoopendaal Roland Bal

2 Hybrid Health Care Systems

3 Institutional layering as a tool to understand hybridity Institutional layering as a type of incremental change (Streeck & Thelen 2005; Mahoney & Thelen 2010): New institutions are added on top of or alongside existing ones Institutional arrangements interact: consequences can be unpredictable Actors can actively shape institutional change

4 Focus on actors Actor approach in institutional layering theory: focus on strategic change agents Actors in a layered institutional arrangement face the consequences of layering in their day-to-day activities Institutional work: daily coping and keeping up with institutional structures, and changing them We combined layering approach and institutional work

5 Layered institutional arrangement Dutch health care Institutional arrangement Important actors Steering instruments Period Market Insurers, health care providers, Competition, closing contracts, Officially introduced as the patients transparency dominant arrangement in 2006 State & hierarchy Ministry of Health, Health care Top down regulation through Always played a role, Inspectorate legislation (e.g. Quality of care importance increased from the act, Individual Healthcare 2000s onwards Professions Act), supervision Civil Society/association Health care professionals, Consultation and deliberation Especially important in the providers, insurers, patient 1990s, still plays a role but less organizations, government dominant then before Professional community Health care professionals Medical training, peer review, Oldest, still highly important but guidelines, visitation, quality less dominant then before. systems

6 Research Question & Methods What are the consequences of institutional layering for the internal governance and the external regulation of health care quality in Dutch hospitals and how do the actors responsible respond to these consequences? Qualitative study: - Interviews with actors playing a role in the internal governance and external regulation of quality (n=18) - Document analysis

7 Consequences of layering: setting things in motion The responsibility for the content of care was completely assigned to professionals for which they did not have to be accountable. This was changed legally with the introduction of the Quality of Care Act in The Boards of Directors legally carry the final responsibility for everything in the organization. That includes the quality and safety of the care process. That has been duly noted for a long time. Nothing happened with that. Until, and that is the first time this was exposed, the Radboud case [case concerning high mortality rates on a ward] (governance expert and former chief inspector)

8 Struggling with layers: a focus on accountability and incidents Relate to many external actors: giving account We have to deal with insane legislation, a completely instable government policy and an enormous amount of organizations that have an opinion. (Governance expert) Incidents lead to shifting arrangements i.e. dominance of state

9 Playing with layers: opportunities for strategic use Actors can actively shape institutions: Say no to certain demands Explain what is not your responsibility Become active in the quality debate Use other actors to get things done They had a big fight with the internists and intensivists and they did not manage to solve that, so then the Inspectorate had to say boo. (quality consultant 3)

10 Conclusions Layering useful heuristic tool to understand the consequences of living in hybrid institutional arrangements better Need to focus on lived experiences of actors: both structure and are structured by institutional context Case study shows this interaction: Layering enables actors involved in governance of quality to play their role Layering also poses problems to play this role Actors engage in institutional work to overcome these problems