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Institutional arrangements used to steer public policies have increasingly become layered. Inspired by the literature on institutional layering and institutional work, this paper aims to make a contribution to our understanding of institutional layering. We do so by studying an interesting case of layering: the Dutch hospital sector. We focus on the actors responsible for the internal governance (Board of Directors and Supervisory Boards) and the external regulation (the Healthcare Inspectorate) of hospitals. In the paper, we explore the institutional work of these actors, more specifically how institutional work results from and is influenced by institutional layering and how this in turn influences the institutional makeup of both healthcare organizations and their institutional context. Our approach allowed us to see that layering changes the activities of actors in the public sector, can be used to strengthen one's position but also presents actors with new struggles, which they in turn can try to overcome by relating and using the institutionally layered context. Layering and institutional work are therefore in continuous interaction. Combining institutional layering with a focus on the lived experiences of actors and their institutional work makes it possible to move into the layered arrangement and better understand its consequences.

Institutional arrangements used to steer public policies have increasingly become layered. Inspired by the literature on institutional layering and institutional work, this paper aims to make a contribution to our understanding of institutional layering. We do so by studying an interesting case of layering: the Dutch hospital sector. We focus on the actors responsible for the internal governance (Board of Directors and Supervisory Boards) and the external regulation (the Healthcare Inspectorate) of hospitals. In the paper, we explore the institutional work of these actors, more specifically how institutional work results from and is influenced by institutional layering and how this in turn influences the institutional makeup of both healthcare organizations and their institutional context. Our approach allowed us to see that layering changes the activities of actors in the public sector, can be used to strengthen one's position but also presents actors with new struggles, which they in turn can try to overcome by relating and using the institutionally layered context. Layering and institutional work are therefore in continuous interaction. Combining institutional layering with a focus on the lived experiences of actors and their institutional work makes it possible to move into the layered arrangement and better understand its consequences.

AbstractThe literature on responsive regulation argues that citizens should be involved in regulatory practices to avoid capture between regulator and regulatee. It also argues that including citizens can add an important perspective to regulatory practices. However, we know little about how citizens' perspectives are brought into regulatory practices. This paper draws on existing qualitative research to compare and analyze four cases of experimental participatory regulation in Dutch health care, focusing on the theoretical assumptions that citizen involvement (a) prevents capture, and (b) stimulates the inclusion of new perspectives. Our results show that involving citizens in regulation can increase transparency and trust in regulatory practices and familiarizes regulators with other perspectives. It is, however, up to the regulator to work on deriving benefits from that involvement—not only the practical work of organizing participatory regulation, but also the conceptual work of reflecting on their own assumptions and standards. We do find evidence for weak forms of capture and argue for the need to extend capture to involve multiple actors. We reflect on these results for theory development and regulatory practice.

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.

AbstractThe centralisation of acute health care is a key policy concern in many countries. Less attention has been given to the side effects of centralisation: peripheralisation, occurring mainly in rural areas and post‐industrial towns. In this research, we start filling this gap by exploring how this trend of concentration of health care can contribute to a phenomenon referred to as 'discursive peripheralisation'. This article contributes to the literature on discursive peripheralisation by focusing on how actors, in our case acute care practitioners, cope with or oppose such processes. We draw on empirical data from two healthcare regions in different geographical contexts in Norway and The Netherlands. In these regions, we zoom in on the work of care practitioners and how they, in relation to care organisations and local authorities, aim to organise care for patients in 'the periphery' and how this contributes to more diverse and alternative narratives and practices of health care in these areas. Our findings offer important insights for both rural and regional policy. We conclude that other narratives, for instance, about perceptions of quality of care should be considered to avoid too much emphasis on the disadvantages faced by peripheral areas, compared to their urban counterparts.

Si l'on s'intéresse de plus en plus à la coproduction dans les soins de santé, on sait peu de choses sur le processus de coproduction. Dans le présent article, nous essayons de comprendre pourquoi les hôpitaux associent les patients et le personnel aux activités de coproduction et analysons les expériences des hôpitaux en matière de coproduction dans la pratique. Une étude qualitative, comprenant des entretiens semi-structurés (N=27), des observations (70 heures) et une analyse documentaire, a été réalisée auprès de cinq hôpitaux néerlandais qui mettaient à contribution les patients et le personnel en vue d'améliorer leurs services. Les résultats indiquent que les hôpitaux ont des raisons variables d'associer les patients et le personnel et qu'ils ont adapté les méthodes existantes pour mettre à contribution les patients. Il est intéressant de noter que les domaines d'amélioration présentés par les patients étaient bien souvent déjà connus. Le processus de coproduction a cependant bel et bien contribué à l'amélioration de la qualité à d'autres égards. Le processus de coproduction a amené les hôpitaux à réfléchir davantage à la manière de réaliser les améliorations de la qualité. Ce processus facilitait les améliorations de la qualité, le fait de voir les patients et d'entendre leurs expériences créant un sentiment d'urgence parmi le personnel, qui réagissait dès lors aux questions d'amélioration soulevées. De plus, les expériences ont eu pour effet de légitimer les améliorations auprès des organes de direction. Remarques à l'intention des praticiens Différentes méthodes de participation peuvent mettre en évidence les expériences des patients en matière de services de soins de santé, ce qui peut servir à améliorer la qualité. Notre étude démontre que le fait d'adapter les méthodes existantes aux ressources hospitalières locales peut être bénéfique pour les processus de coproduction dans un contexte donné. L'adaptation peut cependant aussi présenter des risques. Les activités d'adaptation, comme le recours à des critères pour sélectionner les patients, influencent ce que l'on considère comme la contribution légitime des patients. En outre, compte tenu de l'importance du processus de coproduction, la méthode doit se composer d'une trajectoire organisée, à laquelle les patients et le personnel sont associés et qui met en évidence les expériences personnelles. Les équipes de projet doivent par conséquent poser un regard critique sur les conséquences des adaptations et des actions d'adaptation, ainsi que sur leur opportunité, lors de la mise en œuvre de projets d'amélioration de la qualité.

Co-production in healthcare is receiving increasing attention; however, insight into the process of co-production is scarce. This article explores why hospitals involve patients and staff in co-production activities and hospitals' experiences with co-production in practice. A qualitative study with semi-structured interviews ( N = 27), observations (70 hours) and document analysis was conducted in five Dutch hospitals, which involved patients and staff in order to improve services. The results show that hospitals have different motives to involve patients and staff and have adapted existing methods to involve patients. Interestingly, areas of improvement proposed by patients were often already known. However, the process of co-production did contribute to quality improvement in other ways. The process of co-production stimulated hospitals' thinking about how to realize quality improvements. Quality improvements were facilitated by this process as seeing patients and hearing their experiences created a sense of urgency among staff to act on the improvement issues raised. Moreover, the experiences served to legitimatize improvements to higher management bodies. Points for practitioners Different participation methods can bring patients' experiences with healthcare services to the fore, which can be used for quality improvement. Our study shows that adapting existing methods to local hospital resources is likely to be beneficial for co-production processes within a given context. However, adapting and tailoring also poses risks. Tailoring activities, such as using criteria to select patients, influence what is considered to be legitimate patient input. In addition, as the co-production process is important, the method should consist of an organized trajectory in which patients and staff are involved and personal experiences are presented. Therefore, project teams need to critically reflect on the consequences of adaptations and tailoring actions, and their desirability, when carrying out quality improvement projects.