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In this paper we argue that performance measurement can be done better by general, less accurate measurements than by complex -- and possible more accurate -- ones. The conclusions of this study are drawn from a case study of the Dutch Foundation for Effective Use of Medication. While most studies about performance measurements focus on the management of public service organizations, this case study -- informed by the literature from Science and Technology Studies -- focuses on the active role of the measurements themselves. In the paper we show that indicators do not have to be as complex as the practices they represent -- as long as they are part of a chain of intermediary data that allow travelling from the general or simple indicators to detailed data in day-to-day practices and vice versa. Furthermore, general indicators enable stakeholders to obtain distance from each other. Rather than the involvement of stakeholders, it is this reflexive distancing that explains the degree of compliance to performance measurement and thereby the prospect for effective co-governance. Adapted from the source document.

This paper addresses contemporary reform in postgraduate medical education that aims to standardise training. The reforms are guided by public policy interventions to increase quality of care, objectify performance, and to prepare residents for changing health care needs. This paper draws on an ethnographic study in the Netherlands, studying how new training standards have been incorporated in everyday gynaecology and surgery residency training. Perceiving educational science as a new epistemic culture alongside the traditional professional authority-based epistemic culture, the paper examines how both epistemic cultures have interweaved, fabricating a new training culture that assembles both traditional and 'new' elements.

Background: Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions. Methods: This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings (n=2, with field notes taken) and corresponding audio files (n=3), interviews with appraisal committee members (n=10 in seven interviews) and with Institute employees (n=5 in three interviews), and relevant documents (n=4). Results: We conceptualise decisions as combinations of elements, specifically (quantitative) findings and (qualitative) arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision. Conclusions: Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could further explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy.

In Dutch healthcare, new market mechanisms have been introduced on an experimental basis in an attempt to contain costs and improve quality. Informed by a constructivist approach, we demonstrate that such experiments are not neutral testing grounds. Drawing from semi-structured interviews and policy texts, we reconstruct an experiment on free pricing in dental care that turned into a critical example of market failure, influencing developments in other sectors. Our analysis, however, shows that (1) different market logics and (2) different experimental logics were reproduced simultaneously during the course of the experiment. We furthermore reveal how (3) evaluation and political life influenced which logics were reproduced and became taken as the lessons learned. We use these insights to discuss the role of evaluation in learning from policy experimentation and close with four questions that evaluators could ask to better understand what is learned from policy experiments, how, and why.

In Dutch healthcare, new market mechanisms have been introduced on an experimental basis in an attempt to contain costs and improve quality. Informed by a constructivist approach, we demonstrate that such experiments are not neutral testing grounds. Drawing from semi-structured interviews and policy texts, we reconstruct an experiment on free pricing in dental care that turned into a critical example of market failure, influencing developments in other sectors. Our analysis, however, shows that (1) different market logics and (2) different experimental logics were reproduced simultaneously during the course of the experiment. We furthermore reveal how (3) evaluation and political life influenced which logics were reproduced and became taken as the lessons learned. We use these insights to discuss the role of evaluation in learning from policy experimentation and close with four questions that evaluators could ask to better understand what is learned from policy experiments, how, and why.

AbstractDiscretion used to be considered a feature of individuals, but growing literature shows that it has collective features as well. To develop an understanding of the individual and cooperative work of inspectors in using discretion and the discretionary room granted to them, we compared two inspectorates: theCareQualityCommission (CQC) inEngland and theJointInspectorate forYouth (JIY) in theNetherlands. Our analysis reveals that inspectors engage with colleagues, managers, and stakeholders to include other perspectives, gain mandate, and broaden their repertoire. At theCQC, inspectors use their discretion collectively; on their own initiative, they involve others in balancing and interpreting rules to reach judgments. At theJIY, teamwork is central and regulatory teams are granted collective discretionary room. We argue that collective work permits both responsiveness and consistency. In studying the judgments of inspectors and other street‐level bureaucrats, it is vital to look at collective work and how it combines consistency and responsiveness.

AbstractMachine learning algorithms have begun to enter clinical settings traditionally resistant to digitalisation, such as psychiatry. This raises questions around how algorithms will be incorporated in professionals' practices, and with what implications for care provision. This paper addresses such questions by examining the pilot of an algorithm for the prediction of inpatient violence in two acute psychiatric clinics in the Netherlands. Violence is a prominent risk in acute psychiatry, and professional sensemaking, corrective measures (such as patient isolation and sedation), and quantification instruments (such as the Brøset Violence Checklist, henceforth BVC) have previously been developed to deal with it. We juxtapose the different ways in which psychiatric nurses, the BVC, and algorithmic scores navigate assessments of the potential of future inpatient violence. We find that nurses approach violence assessment with an attitude of doubt and precaution: they aim to understand warning signs and probe alternative explanations to them, so as not to punish patients when not necessary. Being in charge of quantitative capture, they incorporate this attitude of doubt in the BVC scores. Conversely, the algorithmic risk scores import a logic of pre-emption into the clinic: they attempt to flag targets before warning signs manifests and are noticed by nurses. Pre-emption translates into punitive attitudes towards patients, to which nurses refuse to subscribe. During the pilots, nurses solely engage with algorithmic scores by attempting to reinstate doubt in them. We argue that pre-emption can hardly be incorporated into professional decision-making without importing punitive attitudes. As such, algorithmic outputs targeting ethically laden instances of decision-making are a cause for academic and political concern.

AbstractIn this article we examine the fragmented interpretation and implementation of a remarkably popular concept, value‐based health care (VBHC). By building on a case study of a project team working on the development of value‐based primary care services for elderly patients, we shed new light on the way in which VBHC transitions from theory to practice. The concept of 'translation' is used to theoretically frame our analysis. Between June 2021 and May 2022, we gathered data through participant observation (50 h), semi‐structured interviews (n = 20) and document analysis (n = 16). Our findings show how VBHC inspired new ways of working, and that, in line with previous studies, parts of the original concept have been neglected, while others have been modified. We identified three reasons for VBHC's locally varied applications: VBHC transforms to enable a growing support base, the originally radical idea is applied conservatively and the concept tends to get mixed up with other policy objectives. In all, VBHC appears to be successful in catalysing cross‐disciplinary interaction aimed at improving value for patients.

We critically examine the discussion on the role of evidence-based medicine (EBM) in healthcare governance. We take the institutionally layered Dutch healthcare system as our case study. Here, different actors are involved in the regulation, provision and financing of healthcare services. Over the last decades, these actors have related to EBM to inform their actor specific roles. At the same time, EBM has increasingly been problematised. To better understand this problematisation, we organised focus groups and interviews. We noticed that particularly EBM's reductionist epistemology and its uncritical use by 'professional others' are considered problematic. However, our analysis also reveals that something else seems to be at stake. In fact, all the actors involved underwrite EBM's reductionist epistemology and emphasise that evidence should be contextualised. They however do so in different ways and with different contexts in mind. Moreover, the ways in which some actors contextualise evidence has consequences for the ways in which others can do the same. We therefore emphasise that behind EBM's scientific problematisation lurks a political issue. A dispute over who should contextualise evidence how, in a layered healthcare system with interdependent actors that cater to both individual patients and the public. We urge public administration scholars and policymakers to open-up the political confrontation between healthcare actors and their sometimes irreconcilable, yet evidence-informed perspectives.

Recent buzzes around big data, data science and artificial intelligence portray a data-driven future for healthcare. As a response, Europe's key players have stimulated the use of big data technologies to make healthcare more efficient and effective. Critical Data Studies and Science and Technology Studies have developed many concepts to reflect on such overly positive narratives and conduct critical policy evaluations. In this study, we argue that there is also much to be learned from studying how professionals in the healthcare field affectively engage with this strong European narrative in concrete big data projects. We followed twelve hospital-based big data pilots in eight European countries and interviewed 145 professionals (including legal, governance and ethical experts, healthcare staff and data scientists) between 2018 and 2020. In this study, we introduce the metaphor of dreams to describe how professionals link the big data promises to their own frustrations, ideas, values and experiences with healthcare. Our research answers the question: how do professionals in concrete data-driven initiatives affectively engage with European Union's data hopes in their 'dreams' – and with what consequences? We describe the dreams of being seen, of timeliness, of connectedness and of being in control. Each of these dreams emphasizes certain aspects of the grand narrative of big data in Europe, makes particular assumptions and has different consequences. We argue that including attention to these dreams in our work could help shine an additional critical light on the big data developments and stimulate the development of responsible data-driven healthcare.

In this paper, we explore how multiple accountability (MA) can enable an independent regulatory agency to deal with multiple conflicting public values in a complex and politically salient decision-making process. We examined the decision-making process of the Dutch National Health Care Institute on quality regulation of emergency care in the Netherlands. Using insights derived from ethnography, document analysis, and interviews, we show that MA resulted from strategic interactions between the Institute's vertical and horizontal accountability forums. We argue that MA impeded efficiency but also enabled the Institute to deal with multiple conflicting public values.

The allure of a "data-driven" future healthcare system continues to seduce many. Increasingly, work in Science & Technology Studies and related fields started to interrogate the saliency of this promissory rhetoric by raising ethical questions concerning epistemology, bias, surveillance, security, and opacity. Less visible is how ethical arguments are used as part of discursive work by various practitioners engaged in data-driven initiatives in healthcare. This article argues for more explicit attention to such discursive work in shaping the promissory future of data-driven healthcare technologies. Bringing together the hitherto separated themes of promissory futures and an emic approach to ethics as discursive work, we study how actors engaged various data-driven healthcare initiatives discursively conduct such ethics work, implicitly or explicitly assigning tasks and roles for stakeholders. We conceptualize this with the notion of "ethical framing" and identify three widely recurring types: ethics as "balancing act," the technical "fix," and ethics as "collective thought process." We outline the characteristics of these acts of framing and discuss their implications for the envisaged roles and responsibilities of various actors. In the Discussion section, we outline the added value of bringing the distinct bodies of literature on promissory futures and ethical framing together and outline themes for new research.

In this paper, we explore how multiple accountability (MA) can enable an independent regulatory agency to deal with multiple conflicting public values in a complex and politically salient decision-making process. We examined the decision-making process of the Dutch National Health Care Institute on quality regulation of emergency care in the Netherlands. Using insights derived from ethnography, document analysis, and interviews, we show that MA resulted from strategic interactions between the Institute's vertical and horizontal accountability forums. We argue that MA impeded efficiency but also enabled the Institute to deal with multiple conflicting public values.