Onder Zorgbestuurders: Omgaan met bestuurlijke ambiguïteit in de zorg

Van der Scheer onderzocht hoe bestuurders omgaan met de veranderingen in de gezondheidszorg en welke factoren daarop van invloed zijn. Daarvoor ondervroeg ze honderden zorgbestuurders uit verschillende sectoren in 2000, 2005 en 2010 over hun achtergrond, hun taakopvatting en hun tijdsbesteding. Daarnaast analyseerde ze debatten in de politiek en binnen de beroepsvereniging NVZD. Incidenten rond "falend management" domineren in deze periode het politieke debat. Kamerleden grijpen incidenten aan om de regie terug te eisen over de uitvoering van de zorg. Het proefschrift maakt duidelijk dat de overheid, die op papier de regie heeft overgedragen aan de spelers op de "zorgmarkt", in de praktijk de zorg niet wil loslaten. Het proefschrift van Van de Scheer toont ook aan dat zorgbestuurders door het veranderende overheidsbeleid - de introductie van gereguleerde marktwerking - niet heel anders zijn gaan werken. Ondernemen vatten de bestuurders vooral op als "vernieuwen" en "creatief omgaan met beperkte middelen". Bestuurders in de ouderenzorg zijn nog het meest gericht op commerciële activiteiten. De externe veranderingen zijn wel duidelijk terug te zien in de grote aandacht voor verbindingen: met het toenemende aantal partijen waarmee de zorgorganisatie zaken moet doen en tussen de externe eisen, de interne werkprocessen en de professionele opvattingen van zorgverleners. Zorgbestuurders stellen zich tot taak de organisatie aan te passen aan nieuwe eisen, maar willen tegelijkertijd de kernwaarden in de zorg bewaken. Ze voeren veranderingen door, maar temperen die zo nodig ook. Naast veranderingen realiseren gaat besturen ook over het bewaken van de continuïteit. Een andere bevinding van Van der Scheer is dat vrouwen onder de zorgbestuurders in opmars zijn: hun percentage is toegenomen van 11 in 2000 naar 25 in 2010. Daarmee groeide ook het percentage voormalig verpleegkundigen in de raad van bestuur (18% in 2010). Het aandeel vrouwelijke bestuurders is het grootst in de ouderenzorg (30%). De veranderde samenstelling van raden van bestuur werkt door in de functieopvatting. Vrouwelijke respondenten treden meer op als ambassadeur van de organisatie en zien zichzelf meer als een tussenpersoon. Jongere bestuurders houden zich meer bezig met de organisatie zelf, terwijl oudere bestuurders zich meer richten op externe zaken en strategische kwesties. De meeste bestuurders lopen al jaren rond in de gezondheidszorg. De meerderheid is man, de gemiddelde leeftijd 54 jaar

Power, legitimacy and urgency:Unravelling the relationship between Dutch healthcare organisations and their financial stakeholders

Healthcare organisations rely on their financial stakeholders for capital to invest in state-of-the-art buildings, equipment, innovation and the delivery of healthcare services. Nevertheless, relations between healthcare organisations and their financial stakeholders have not been well studied. Here, we studied the relations between Dutch healthcare organisations and two of their main financial stakeholders (banks and health insurers) against the backdrop of system reforms and the financial crisis. We conducted a survey of healthcare executives to evaluate their relations with banks and health insurers in terms of power, legitimacy and urgency. These three attributes are based on the salience model of Mitchel, Agle and Wood (1997). We further tested for differences in power, legitimacy and urgency across organisational sector and size. The results showed that healthcare organisations value banks as legitimate stakeholders with a well-demarcated influence and a clear-cut function. The relationship with health insurers is more complex. Healthcare organisations experience considerable influence from health insurers but question the legitimacy of their claims. Since health insurers play a crucial role in the Dutch healthcare system, these findings question the workability of the relationship between healthcare organisations and health insurers and the position of health insurers in the overall healthcare sector. Our results are relevant to countries with public-private health systems and contribute to the development of the salience model by showing the individual value of stakeholder attributes and the relevance of context

Bedtime negotiations:Unravelling normative complexity in hospital-based prevention

This study explores how actors deal with normative complexity in the design and implementation of practices of preventative care. Previous studies have identified conflicting (e)valuations of prevention within health care at large, but little empirical research describes how these conflicts are resolved in day-to-day interactions. Zooming in on the work of a single actor, our ethnographic study describes a Dutch psychiatrist developing a novel type of hospital bed that provides preventative psychiatric care for women in the post-partum period. Drawing on pragmatic sociology of justification, we construe ‘beds’—and the time, people and resources they represent—as points of convergence between conflicting valuations of care. The results show that embedded modes of valuation in a curative hospital setting generate significant normative complexity during implementation. We identify three main strategies through which normative complexity is managed: (a) translating between different modes of valuing prevention, (b) compromising in (material) design of care beds and (c) transcending embedded valuations through moral appeals. By showing the normative complexity of prevention in practice, our study highlights the need for a diverse and situated accounting for preventative care.</p

Health care reform and financial crisis in the Netherlands:consequences for the financial arena of health care organizations

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands – where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted – provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.<br/

For better or worse:Governing healthcare organisations in times of financial distress

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress

For better or worse:Governing healthcare organisations in times of financial distress

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress

Health care reform and financial crisis in the Netherlands:consequences for the financial arena of health care organizations

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands – where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted – provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.<br/

Heath care exectives don't find conditions health insurers appropriate

IN HET KORT● Zorgbestuurders ervaren veel macht en urgentie van zorgverzekeraars, maar vinden hun eisen beperkt wenselijk en passend.● Zorgbestuurders ervaren de meeste invloed van zorgverzekeraarswat betreft financiën, strategievoering en de kwaliteit van zorg.● Een gedeelde langetermijnvisie zou de kwaliteit van samenwerking kunnen bevorderen en het zorgstelsel werkbaar houden