Annemiek Stoopendaal

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. 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. 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. 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.

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.

The Dutch Healthcare Inspectorate has recently tried out a new form of inspection: System-Based Regulation (SBR). This article explores how SBR was situated in the healthcare context through a process of ‘experimentalist governance’. A qualitative formative evaluation was undertaken involving two years of participative observation, numerous iterations between data gathering and feedback in order to orient the next steps of the process. The evaluation found that SBR could fit into the existing supervisory regime, but notwithstanding positive outcomes SBR was controversial and further implementation was delayed. The process of ‘experimentalist governance’ was strengthened by qualitative formative evaluation that documented and reflected on the process as it progressed. The evaluation also helped to translate and communicate learning so as to better understand regulation and to reform and reconceptualize SBR in today’s healthcare context.

Developing the concepts of governance and regulation is path dependent: working with the complexity of governance and regulation shapes and reshapes both their meaning and form. We conducted a case study on governance and regulation of quality and safety in Dutch hospitals to reveal these processes. We found that governance was given meaning in several phases, ranging from a focus on institutional design (e.g. corporate governance) through coping with incidents and using quality measurements, to prospective risk management. Governance changed incrementally in form and practice. We also saw that governance and regulation are intertwined; regulation shapes governance and is simultaneously shaped by changes in the meaning of governance. Insight into these processes is important to better understand what is defined as “good governance” and “good regulation” in a certain context. Understanding the mutual development of these concepts and practices reveals potential pathways to continuous shaping of good governance.