Tackling the problem of regulatory pressure in Dutch elderly care: The need for recoupling to establish functional rules.

Regulatory pressure is widely recognized as a problem in healthcare. At first sight the solution seems simple: discard rules and give caregivers more resources to provide personalized care. Based on qualitative research in four elderly care organizations in the Netherlands, this paper shows that regulatory pressure is a persistent problem that cannot be solved on an individual level, as it results from a disconnect between the work of different actors in the healthcare system. Drawing on concepts from Organization Studies, the paper shows that the work of caregivers, healthcare managers and external actors is often decoupled. Caregivers experience regulatory pressure when the origin and function of rules are unclear. The studied care organizations are experimenting with rules, reconsidering and creating functional rules. They do so by stimulating reflection among actors in the healthcare system, thereby recoupling their work. The findings suggest that recoupling can be achieved by creating comfort zones, focusing on stimulating debate between stakeholders on the functionality and origin of rules and aligning ideas about good quality care, the role different actors can play and the rules that are needed to accommodate this.

An empirical study of how the Dutch healthcare regulator first formulates the concept of trust and then puts it into practice.

BACKGROUND: Responsive regulation assumes that the parties being regulated are trustworthy and motivated by social responsibility. This assumes that regulation based upon trust will improve the regulated organization more effectively than other regulation models. The purpose of our qualitative study was to unravel the most important elements of trust in the inspectee which can support the inspector's work and to develop a model and a framework of trust that can be used by the inspectors to legitimize their trust in the inspectee. METHODS: We conducted an empirical study on trust regarding the regulation of care services to reveal how trust in the inspectee is conceptualized and assessed. Based on literature and empirical research, we synthesized the concept of trust into six elements, five regarding behavior, and a sixth looking at information about its context. We developed a practical framework for the concept to reduce the conceptual ambiguity, strengthen regulatory assessment, and support appropriate tailoring of the regulatory response. RESULTS: Six elements with respect to trust emerged from the data: showing integrity; transparency; ability to learn; accepting feedback; showing actual change in behavior; context information. These five behavioral elements, plus the context information were merged into a Framework of Trust and designed into an interactive PDF document. CONCLUSIONS: This study has sought to address a gap in the empirical knowledge regarding the assessment of trust in the inspectee. The results aim to inform and clarify the regulatory conceptualization and understanding of trust in the inspectee. Other inspectorates may learn from these results for their own practice and explore whether operational deployment of our Framework of Trust effects their assessment and enforcement strategies.

What are the perceived added values and barriers of regulating long-term care in the home environment using a care network perspective: a qualitative study.

BACKGROUND: Changes in Dutch policy towards long-term care led to the Dutch Health and Youth Care Inspectorate testing a regulatory framework focusing on care networks around older adults living independently. This regulatory activity involved all care providers and the older adults themselves. METHODS: Semi-structured interviews with the older adults, and focus groups with care providers and inspectors were used to assess the perceived added value of, and barriers to the framework. RESULTS: The positive elements of this framework were the involvement of the older adults in the regulatory activity, the focus of the framework on care networks and the open character of the conversations with the inspectors. However, applying the framework requires a substantial investment of time. Care providers often did not perceive themselves as being part of a care network around one person and they expressed concerns about financial and privacy issues when thinking in terms of care networks. CONCLUSIONS: The experiences of the client were seen as important in regulating long-term care. Regulating care networks as a whole puts cooperation between care providers involved around one person on the agenda. However, barriers for this form of regulation were also perceived and, therefore, careful consideration when and how to regulate care networks is recommended.

Exploring a transition in Dutch healthcare.

PURPOSE: Healthcare systems are facing persistent challenges, such as dealing with an ageing population, related increases in chronic diseases and healthcare costs facilitated by technological progress. The authors argue that the boundaries of optimisation are being reached and a more fundamental change or transition is necessary. The purpose of this paper is to explore the contours of this transition in the Netherlands. The authors do this from the perspective of healthcare organisations that have participated in the "Expedition to Sustainable Healthcare": a learning programme organised by the Dutch Network for Sustainable Healthcare aimed at creating frontrunners in this transition. DESIGN/METHODOLOGY/APPROACH: The paper combines conceptual with experimental empirical work. The authors use the transition research frameworks to conceptualise persistent problems and transitional dynamics in the healthcare system. In a longitudinal study, the authors analysed how the participating organisations developed after the expedition. FINDINGS: The process validated the initial understanding of persistent sustainability challenges. An integral approach to sustainable healthcare is translated as a transformation of culture, structures and practices and the development of capacity for crossing borders and domains, inside and outside of the organisation. To facilitate and stimulate such a process the authors found that problem structuring and collective identification of persistent problems and the unsustainability in the healthcare system is a crucial step towards a shared view and discourse that supports change. ORIGINALITY/VALUE: A transition in the Dutch healthcare system is just starting to emerge and has barely been subject of research. This paper provides an empirical description of a transition management process in this context. The authors hope to lay a foundation for future work that seeks to explore transitions in healthcare in theory and practice.

What hospitals need to know about guidelines-A mixed-method analysis of guideline implementation in Dutch hospitals.

RATIONALE, AIMS AND OBJECTIVES: This study provides insight into how Dutch hospitals ensure that guidelines are used in practice and identifies what key messages other hospitals can learn from existing practices. We examine current practices in handling compliance and, therefore, focus on hospitals that reported that they do not experience problems in the implementation of guidelines. METHOD: A survey of Dutch hospital boards and 9 semistructured interviews were conducted with a purposive sample of 3 hospitals. Interviews were held with 3 representatives of each hospital, specifically, with a member of the board of directors, a member of the executive medical staff, and the manager of the quality and safety department. RESULTS: Hospitals find guidelines necessary and useful. Hospitals have the power to improve implementation if boards of directors and medical staff are committed, intrinsically motivated, cooperate with each other, and use guidelines pragmatically. Even then, they prioritize guidelines, as resources are scarce. Despite their good work, all hospitals in this study appeared to struggle to adhere to guidelines. CONCLUSIONS: If hospitals experience problems with guideline implementation, they tend to focus more on external expectations, leading to defensive behaviour. Hospitals that do not experience implementation problems focus more on integrating guidelines into their own policies.

Working with layers: The governance and regulation of healthcare quality in an institutionally layered system.

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.

Government supervision on quality of smoking-cessation counselling in midwifery practices: a qualitative exploration.

BACKGROUND: The Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence. METHODS: We conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate. RESULTS: Our results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling. CONCLUSION: Motivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.

From boundaries to boundary work: middle managers creating inter-organizational change.

Purpose In healthcare, organizational boundaries are often viewed as barriers to change. The purpose of this paper is to show how middle managers create inter-organizational change by doing boundary work: the dual act of redrawing boundaries and coordinating work in new ways. Design/methodology/approach Theoretically, the paper draws on the concept of boundary work from Science and Technology Studies. Empirically, the paper is based on an ethnographic investigation of middle managers that participate in a Dutch reform program across health, social care, and housing. Findings The findings show how middle managers create a sense of urgency for inter-organizational change by emphasizing "fragmented" service provision due to professional, sectoral, financial, and geographical boundaries. Rather than eradicating these boundaries, middle managers change the status quo gradually by redrawing composite boundaries. They use boundary objects and a boundary-transcending vocabulary emphasizing the need for societal gains that go beyond production targets of individual organizations. As a result, work is coordinated in new ways in neighborhood teams and professional expertise is being reconfigured. Research limitations/implications Since boundary workers create incremental change, it is necessary to follow their work for a longer period to assess whether boundary work contributes to paradigm change. Practical implications Organizations should pay attention to conditions for boundary work, such as legitimacy of boundary workers and the availability of boundary spaces that function as communities of practice. Originality/value By shifting the focus from boundaries to boundary work, this paper gives valuable insights into "how" boundaries are redrawn and embodied in objects and language.

Professional Talk: How Middle Managers Frame Care Workers as Professionals.

This paper examines how middle managers in the long term care sector use the discourse of professionalism to create 'appropriate' work conduct of care workers. Using Watson's concept of professional talk, we study how managers in their daily work talk about professionalism of vocationally skilled care workers. Based on observations and recordings of mundane conversations by middle managers, we found four different professional talks that co-exist: (1) appropriate looks and conduct, (2) reflectivity about personal values and 'good' care, (3) methodical work methods, (4) competencies. Jointly, these professional talks constitute an important discursive resource for middle managers to facilitate change on the work floor. Change involves the reconfiguration of care work and different managerial-worker relations. Middle managers use professional talks in both enabling and disenabling ways vis-à-vis care workers. Based on these findings, we suggest a more nuanced portrayal of the relationship between managers and professionals. Rather than being based on an intrinsic opposition, i.e. 'managers versus professionals', this relationship is flexibly reconstructed via professional talk.

Managing different forms of distances in Dutch healthcare organizations: The relation between managers and professionals as a dynamic continuum of distance and proximity.

PURPOSE: Dichotomous "gap" thinking about professionals and managers has important limits. The purpose of this paper is to study the specific ontology of "the gap" in which different forms of distances are defined. DESIGN/METHODOLOGY/APPROACH: In order to deepen the knowledge of the actual day-to-day tasks of Dutch healthcare executives an ethnographic study of the daily work of Dutch healthcare executives and an ontological exploration of the concept "gap" was provided. The study empirically investigates the meaning given to the concept of "distance" in healthcare governance practices. FINDINGS: The study reveals that healthcare executives have to fulfil a dual role of maintaining distance and creating proximity. Coping with different forms of distances seems to be an integral part of their work. They make use of four potential mechanisms to cope with distance in their healthcare organization practices. ORIGINALITY/VALUE: The relationship between managers and professionals is often defined as a dichotomous gap. The findings in this research suggest a more dynamic picture of the relationship between managers and professionals than is currently present in literature. This study moves "beyond" the gap and investigates processes of distancing in-depth.

A care improvement program acting as a powerful learning environment to support nursing students learning facilitation competencies.

Change management is an important area of training in undergraduate nursing education. Successful change management in healthcare aimed at improving practices requires facilitation skills that support teams in attaining the desired change. Developing facilitation skills in nursing students requires formal educational support. A Dutch Regional Care Improvement Program based on a nationwide format of change management in healthcare was designed to act as a Powerful Learning Environment for nursing students developing competencies in facilitating change. This article has two aims: to provide comprehensive insight into the program components and to describe students' learning experiences in developing their facilitation skills. This Dutch Regional Care Improvement Program considers three aspects of a Powerful Learning Environment: self-regulated learning; problem-based learning; and complex, realistic and challenging learning tasks. These three aspects were operationalised in five distinct areas of facilitation: increasing awareness of the need for change; leadership and project management; relationship building and communication; importance of the local context; and ongoing monitoring and evaluation. Over a period of 18 months, 42 nursing students, supported by trained lecturer-coaches, took part in nine improvement teams in our Regional Care Improvement Program, executing activities in all five areas of facilitation. Based on the students' experiences, we propose refinements to various components of this program, aimed at strengthenin the learning environment. There is a need for further detailed empirical research to study the impact this kind of learning environment has on students developing facilitation competencies in healthcare improvement.

[Resilience and patient safety: how can health care regulations contribute?]. / Veerkracht en veiligheid: hoe kan regulering van de zorg daaraan bijdragen?

The discussion on patient safety in the Netherlands appears to have reached an impasse. Healthcare professionals are feeling uncomfortable with the enormous increase in the numbers of norms and guidelines, the focus on error and the pressure from external parties. In this article, based on the conference Safety II and beyond - resilience meets regulation, held in Rotterdam, the Netherlands in June 2015, we discuss the underlying problems and propose an alternative approach to the concept of patient safety and to measures to guarantee this safety.

Conferences, tablecloths and cupboards: how to understand the situatedness of quality improvements in long-term care.

Long term care needs improvement, but still little is known how quality improvement works in practice. A better, in-depth, understanding of the content and complexities of quality improvement is necessary because of the still limited theoretical and empirical grounds underlying its approach. This article draws on empirical material from Care for Better, a national quality improvement collaborative (QIC) for the long-term care sector in the Netherlands that took place from 2005 until 2012. Following a project on prevention of malnutrition, we analyzed the complex and ongoing processes of embedding improvements. The guiding question for our research was: what must be accomplished to enable and sustain improvements to occur in the everyday life of care organizations? In our analysis, we linked ethnographic findings to Actor Network Theory. We found that different kinds of work had to be done by both human and non-human actors to displace improvements into specific organizational situations. We conceptualized this work as the activity of translation. Moreover, the concept of inscription offers a perspective to reveal how improvements are made durable. Inscriptions are translations of values into texts, behavior or materialities that steer action in a specific way. We analyzed three different modes of inscription: gathering, materializing and training. We analyzed how one specific value, patient choice, became inscribed in different ways, configuring the actors in specific ways, with diverging consequences for how patient choice comes about.