Lecture 3
Governance and Strategy
Working with layers as a healthcare manager
Looking at governance from a healthcare manager perspective. Lecture 2 was governance
from a citizen perspective.
Agenda
- Institutional layering and institutional work
- How can such theory help you in your analysis (presentations)
- Examples from mental hc practice
- Conclusion: linking theory to practice
Institutions
- Power structure (the position of the medical professional in a hospital)
- Insurance
- Markets
- Organizations
- Marriage (social institutions which come with social expectations/norms)
- Parliament
Why should we care?
- Institutional theory views institutions as:
o relatively enduring features of political and social life (e.g. rules, norms,
procedures) that structure behavior and that cannot be changed easily or
instantaneously (Mahoney & Thelen 2010, p.4)
- Institutions set incentives and constraints for action: they determine the rules of the
game (e.g. how are decisions being made, who makes the decisions)
- Institutional theory can help us understand how governance works
- It helps to understand how policy changes work out and how actors in the hc system
deal with them (bc changes are made in a certain setting/institution/system, so
influenced by it)
Theory incremental change and institutional work
Theory on incremental change (Mahoney & Thelen 2010)
- Institutions viewed as distributional instruments laden with power implications
(determines who can make decisions about sth), this:
o Makes institutions fraud with tenstions, which makes them dynamic (after
the system change the insurers had a different power/role)
o Actors will try to change these power relations, because some actors will
want more decision-making power (makes them dynamic). So institutions are
not just static, they have power relations and change constantly
- Institutional change and stability requires work
- Dynamic nature opens up many internal and external possibilities for change (have
to look at how actors work to change the dynamic in order to understand hc
governance)
1
, Different types of institutional change
- Displacement: the removal of existing rules and the introduction of new ones
- Layering: the introduction of new rules on top of or alongside existing ones
- Drift: the changed impact of existing rules due to shifts in the environment
- Conversion: the changed enactment of existing rules due to their strategic
redeployment (so have a certain rule, but one interprets it differently bc that
interpretation suits them better)
Institutional work (Lawrence et al. 2011)
- Activities of actors to change or maintain institutions has been conceptualized as
institutional work:
o Daily coping and keeping up with institutional structures thereby creating,
disrupting and maintaining institutions (so everyday institutional interaction
can create change)
- To study institutional change: need a focus on institutional work
How can this theory help in the analysis for the group presentations
Typology of institutional arrangements
In Holland, we have a little bit of everything.
Hisotry of governance of quality in hospitals in the NL: case of institutional layering
- Historically strong focus on self-regulation
- From the 1980s onwards associational arrangement with consultation with societal
actors: resulted in implementation of amongst others the Quality of care Act
- Increased state regulation beginning of 2000s
- Introduction of a market based system (officially introduced in 2006, after long
process of incremental change – Helderman 2005)
Interactions between layers
- Regulated market and self-regulation:
o Limits self-regulation, but self-regulation not a thing of the past
2
Governance and Strategy
Working with layers as a healthcare manager
Looking at governance from a healthcare manager perspective. Lecture 2 was governance
from a citizen perspective.
Agenda
- Institutional layering and institutional work
- How can such theory help you in your analysis (presentations)
- Examples from mental hc practice
- Conclusion: linking theory to practice
Institutions
- Power structure (the position of the medical professional in a hospital)
- Insurance
- Markets
- Organizations
- Marriage (social institutions which come with social expectations/norms)
- Parliament
Why should we care?
- Institutional theory views institutions as:
o relatively enduring features of political and social life (e.g. rules, norms,
procedures) that structure behavior and that cannot be changed easily or
instantaneously (Mahoney & Thelen 2010, p.4)
- Institutions set incentives and constraints for action: they determine the rules of the
game (e.g. how are decisions being made, who makes the decisions)
- Institutional theory can help us understand how governance works
- It helps to understand how policy changes work out and how actors in the hc system
deal with them (bc changes are made in a certain setting/institution/system, so
influenced by it)
Theory incremental change and institutional work
Theory on incremental change (Mahoney & Thelen 2010)
- Institutions viewed as distributional instruments laden with power implications
(determines who can make decisions about sth), this:
o Makes institutions fraud with tenstions, which makes them dynamic (after
the system change the insurers had a different power/role)
o Actors will try to change these power relations, because some actors will
want more decision-making power (makes them dynamic). So institutions are
not just static, they have power relations and change constantly
- Institutional change and stability requires work
- Dynamic nature opens up many internal and external possibilities for change (have
to look at how actors work to change the dynamic in order to understand hc
governance)
1
, Different types of institutional change
- Displacement: the removal of existing rules and the introduction of new ones
- Layering: the introduction of new rules on top of or alongside existing ones
- Drift: the changed impact of existing rules due to shifts in the environment
- Conversion: the changed enactment of existing rules due to their strategic
redeployment (so have a certain rule, but one interprets it differently bc that
interpretation suits them better)
Institutional work (Lawrence et al. 2011)
- Activities of actors to change or maintain institutions has been conceptualized as
institutional work:
o Daily coping and keeping up with institutional structures thereby creating,
disrupting and maintaining institutions (so everyday institutional interaction
can create change)
- To study institutional change: need a focus on institutional work
How can this theory help in the analysis for the group presentations
Typology of institutional arrangements
In Holland, we have a little bit of everything.
Hisotry of governance of quality in hospitals in the NL: case of institutional layering
- Historically strong focus on self-regulation
- From the 1980s onwards associational arrangement with consultation with societal
actors: resulted in implementation of amongst others the Quality of care Act
- Increased state regulation beginning of 2000s
- Introduction of a market based system (officially introduced in 2006, after long
process of incremental change – Helderman 2005)
Interactions between layers
- Regulated market and self-regulation:
o Limits self-regulation, but self-regulation not a thing of the past
2
