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Patient organizations increasingly play an important role in health care decision-making in Western countries. The Netherlands is one of the countries where this trend has gone furthest. In the literature some problems are identified, such as instrumental use of patient organizations by care providers, health insurers and the pharmaceutical industry. To strengthen the position of patient organizations government funding is often recommended as a solution. In this paper we analyze the ties between Dutch government and Dutch patient organizations to learn more about the effects of such a relationship between government and this part of civil society. Our study is based on official government documents and existing empirical research on patient organizations. We found that government influence on patient organizations has become quite substantial with government influencing the organizational structure of patient organizations, the activities these organizations perform and even their ideology. Financing patient organizations offers the government an important means to hold them accountable. Although the ties between patient organizations and the government enable the former to play a role that can be valued as positive by both parties, we argue that they raise problems as well which warrant a discussion on how much government influence on civil society is acceptable.

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.

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.

Since the 1980s, regulated markets and New Public Management have been introduced in the public sector across the world. How they have affected existing governance mechanisms such as self-regulation and state regulation has remained largely unexplored, however. This article examines the origins and consequences of institutional layering in governing healthcare quality. Dutch health care, where a market-based system has been introduced, is used as a case study. The results show that this market-based system did not replace but modified existing institutional arrangements. As a result, hospitals have to deal with the fragmentation of quality demands. Using the concept of institutional layering, this study shows how different arrangements interact. As a consequence, the introduction of a certain policy reform will work out differently in different countries and policy sectors. Our 'archaeological' study in this layering can be seen as an example of how such incremental change can be studied in detail. Adapted from the source document.