Working with layers: The governance and regulation of healthcare quality in an institutionally layered system
| Author | Hester M van de Bovenkamp,Roland Bal,Annemiek Stoopendaal |
| DOI | 10.1177/0952076716652934 |
| Date | 01 January 2017 |
| Published date | 01 January 2017 |
| Subject Matter | Articles |
Public Policy and Administration
2017, Vol. 32(1) 45–65
!The Author(s) 2016
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DOI: 10.1177/0952076716652934
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Article
Working with layers:
The governance and
regulation of
healthcare quality
in an institutionally
layered system
Hester M van de Bovenkamp,
Annemiek Stoopendaal and Roland Bal
Erasmus University Rotterdam, The Netherlands
Abstract
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 institu-
tional work results from and is influenced by institutional layering and how this in turn
influences the institutional makeup of both healthcare organizations and their institu-
tional 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.
Keywords
Healthcare, institutional layering, institutional work, public administration, public
management, regulation
Corresponding author:
Hester M van de Bovenkamp, Erasmus University Rotterdam, Institute of Health Policy and Management,
Postbus 1738, 3000 DR Rotterdam, The Netherlands.
Email: vandebovenkamp@bmg.eur.nl
Introduction
Institutional contexts in the public sector have become increasingly complex as they are
built on different institutional arrangements that exist at the same time. For example,
the introduction of regulated markets and other New Public Management (NPM)-like
interventions were not accompanied by the elimination of other institutional arrange-
ments such as professional self-regulation and consensus building between stake-
holders. Instead, these preexisting arrangements have become incorporated in
and conditioned by regulated markets. Therefore, the introduction of regulated mar-
kets in Western European countries meant that increasingly complicated mixed
arrangements to govern public policies were created (Streeck and Thelen, 2005),
which public service providers have to relate to. In t his paper, we explore what this
means for actors working in these organizations, how they respond to these layered
arrangements, and how they in turn influence this institutional context. For this
exploration,we draw on the concepts of institutionallayering and institutional work.
The concept of institutional layering has been introduced to better understand
complex arrangements and how they came about (Mahoney and Thelen, 2010;
Streeck and Thelen, 2005). Institutional layering is a type of institutional change
in which new institutions are added on top of or alongside existing ones.
Institutional layering does not mean that new arrangements simply overlie others
but that arrangements interact with each other, which can lead to large and unpre-
dictable transformations (Mahoney and Thelen, 2010; Streeck and Thelen, 2005).
These transformations can have important consequences for actors working in
such a layered arrangement. Much literature on layering describes the historical
process of layering and focuses on its consequences on policies and the actions of
actors at the macro level (e.g. Beland, 2007; Parker and Parenta, 2008; Thatcher
and Coen, 2008). However, in this article we take a somewhat different focus.
Instead of researching the process of layering, we take layered institutional envir-
onments as our starting point and explore the undertheorized issue of how actors
working in organizations that have to relate to such an institutionally layered
context engage with this context.
The literature on layering acknowledges the important role actors play as change
agents who strategically wish to bring about institutional change (Hacker, 2004;
Mahoney and Thelen, 2010; Scheingate, 2010). In this article, we extend this actor
approach by introducing the concept of institutional work from the Organization
Sciences. This literature took a similar actor-focused turn as its Public
Administration counterpart, by focusing on the work of actors that actively shape
institutions (Currie et al., 2012; Lawrence et al., 2011). However, institutional work
does not only comprise the strategic use of the institutional context in order to bring
about certain changes, as is the focus in Public Administration literature,but also the
daily copingand keeping up with institutionalstructures (Lawrenceet al., 2011). Such
daily work, as is shown for example in literature on organizational routines, both
works to sustain and change prevailing institutional structures (Feldman and
Pentland, 2003).Using the concept of institutionalwork in our study on institutional
layering allowsus to better understand the dynamicscaused by institutional layering.
46 Public Policy and Administration 32(1)
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