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Summary Governance & Strategy Lectures & Literature
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All lectures and obligatory literature of Governance & Strategy (made May 2021)
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Lecture 1The outer context (social environment, culture, technology, politics, law) can influence the inner
context (organizational characteristics) and vice versa, there is connection
Context
- Healthcare systems (marco): Health policies, role of patients and citizens, view on care and
health, role of professional and patient associations
- Healthcare organisations (meso): Health policies travel downwards and shape the everyday
reality of care organizations, role of managers, professionals, patients, municipalities, social
care, etc.
- Day-to-day interactions of individuals (micro): Between professionals and patients/care
takers, between professionals and managers
Government to governance
Governance: elements of steering
From government (places of power, centralized power, directed in top-down, powerful government
representatives determine outcomes of decision-making, political decision are made e.g., in The
Hague, but are implemented elsewhere in the country) to governance (decentralisation of
responsibility: e.g., to market, municipalities, community, public/ private providers or European
Union).
- Hollowing out the state: more responsibility from government to other stakeholder, their
level of control has decreased
Strategy
Heading into a certain direction and aiming for a certain goal. Keep flow in changing the outer
context of your organization, everything around you change, therefore you have to adapt as well.
Rhodes: Understanding governance: Ten years on
Macro
Policy networks
Set of formal and informal institutional linkages between government and other actors structured
around shared interests in public policymaking and implementation. These institutions are
interdependent. Policies emerge from the bargaining between the networks’ members. Any
organisation is dependent upon other organisations for resources, in order to achieve their goals,
organization exchange resources. Although decision-making within organization is constrained by
other organizations, the dominant coalition retains some discretion. The dominant coalition employs
strategies within known rules of the game to regulate the process of exchange. The degree of
discretion is a product of the goals and the relative power potential of interacting organization.
- Corporate management and marketization lead to fragmentation and created pressure to
cooperate with other services -> so: marketization multiplied networks (is paradoxically).
Networks are characterized by trust and diplomacy.
- With the spread of networks there has been a recurrent tension between contracts on the one
hand, with their stress on competition to get the best price, and networks on the other, with
their stress on cooperative behaviour (trust is essential for cooperative behaviour – networks are
high on trust and contracts low on trust)
,Governance
Governance refers to a new process of governing or a changed condition of ordered rule or the net
method by which society of governed.
Definition governance: Governing with and through networks:
1. Interdependence between organizations. Governance is broader than government, covering
non-state actors. Changing the boundaries of the state meant the boundaries between
public, private and voluntary sectors became shifting and opaque.
2. Continuing interactions between network members, caused by the need to exchange
resources and negotiate shared purposes.
3. Game-like interactions, rooted in trust and regulated by rules of the game negotiated and
agreed by network participants.
4. A significant degree of autonomy from the state. Networks are not accountable to the state;
they are self-organizing. Although the state does not occupy a privileged, sovereign position,
it can indirectly and imperfectly steer networks’
Network governance has two faces: (1) public sector change (can be increased fragmentation and
joined-up governance) and (2) interprets British government; the hierarchic model of responsible
government is no longer acceptable.
Core executive
Power-dependency: Who does what? Who has what resources? à power lies not within specific
positions but it’s relation between (people who occupy) different positions à power is contingent
and relational.
Hollowing out of the state:
The growth of governance reduced the ability of the core executive to act effectively, making it less
reliant on a command operating code and more reliant on diplomacy. The state has been hollowed
out from above (international), from below (marketization and networks) and sideways (agencies).
Key criticisms
Common criticism on policy network analysis: pays too little attention to change and the role of ideas
in change. The danger is that identifying categories of exogenous change (economic, ideological,
knowledge and institutional) imply that change is independent of the policy network. Yet, actors in
the network shape and construct their world (choosing how to respond).
Role of the state: I accept there is a ‘persistent asymmetry’ between a constitutional superior
(central government) and a constitutional subordinate (local government), because the centre can
unilaterally change the rules of the game.
Critique on Hollowing out the state: ‘shadow of hierarchy’ à central government does have a final
say. However, the government is not dominant à governments fail because they are locked into
power-dependent relations and because they must work with and through complex networks of
actors and organizations. To adopt a command operating code builds failure into the design of the
policy. Such centralization will be confounded by fragmentation and interdependence which, in turn,
will prompt further bouts of centralization
Summary of British government: the differentiated policy
Its core ideas are policy networks, governance, the core executive and hollowing out and it argues
there has been a shift from government by a unitary state to governance through and by networks.
,- Differentiation became more extensive in the 1980s and 1990s, which saw significant changes in
the functional and territorial specialization of British government; the networks have multiplied
as an unintended consequence of marketization; that the degree of international
interdependence is greater and that, as a result, the core executive’s capacity to steer is reduced
or hollowed out serve to reinforce the interpretation that centralization and control are
incomplete and Britain is best viewed as a differentiated polity
The author clearly states his story will never end. It has no end to look at the government
Therefore, the author used the decentred theory as the new way to see alternative ways of
conceptualizing the institutions, actors and processes of change in government’
Riley and Manias: Governance in operating room nursing
Micro
Abstract
This paper explores governance and control in operating room nurses’ clinical practice à nurses are
often conceptualised as handmaidens of surgeons a position which implies that nurses’ bodies and
the knowledge, they use in practice are sites of discursive control by others. However, nurses actively
shape practice in operating room by knowing surgeon’s technical requirements, they inscribed them
in discourses of time, and they have deep knowledge about the surgeon’s ‘soul’ etc. à this is a form
of governance: it transcends the traditional lines of authority and control in the nurse-doctor
relationship
Background
We contend that operating room nurses have historically been constructed as subservient
handmaidens to surgeons, lacking governance and control of their own work environment.
Analysis
Approach by Foucault: understanding government beyond the official capacities of state to that of
the individual à governmentality: combining ideas of government and mentality (how is though
about governing). It is concerned not only with the tactics and practices of government, but also with
practices of the self that shape and mould the individual through directing choices, desired
aspirations and needs
Results
Three different ways were identified in which nurses used their knowledge of surgeons to govern
practice.
- Technical knowledge of surgeons
o Operating room nurses knew surgeons’ technical requirements for surgery—the specific
instruments and supplies preferred by each surgeon. ‘’Surgeons Preference Cards’’ were
made, which enabled nurses to anticipate and pre-empt what was needed for surgery
and provided the ‘‘material infrastructure’’ of practice.
- Inscribing bodies in time
o Nurses’ not only know the preferences of surgery, but also the habits of each surgeon.
There were power relationships and interprofessional tensions between nurses and
doctors as each strives to control time. E.g. a surgeon was known to be ‘always late’ and
how this surgeon arranged the order of his lists so that the short cases were performed
first, leaving the more complicated, longer, procedures until last to avoid cancellation.
- Deep knowledge of surgeon
, o Nurses had insight into surgeons’ disposition, knowing them as someone who gets
stressed or as someone who is relaxed, someone who is approachable during surgery or
someone to be avoided, and as someone who is pedantic or alternatively, ‘‘slack’’ à This
deep knowledge became apparent in nurses’ communication practices of prudent silence
and gatekeeping.
Discussion
The “calculable traces of individuality” about surgeons, their technical requirements, as beings
inscribed in time, and deep knowledge of their soul, allowed nurses to take actions to coordinate and
organise their work routines. The nurses have techniques of governmentality through which nurses
exercised power to shape and control practice. That is, through having knowledge of individual
surgeons, operating room nurses were active social agents in governing their practice and
subjectivity à they can control their own behaviour and autonomy but also the behaviour of the
surgeon
Governance: control behaviour and the clinical practice
- Using Foucault, a more productive and constitutive account of relationship can be reached à
The different ways in which nurses come to know surgeons, the ways they construct them as
objects of knowledge, is a source of power-knowledge for operating room nurses, through which
they govern and control their practice
Scholten, Muijsers-Creemers, Moen, Bal: Structuring ambiguity in hospital
governance
Meso
Abstract
Research into developing governance structures highlights the strategies of four Dutch hospitals to
strengthen their governability. The hospitals studied choose to commit themselves to duality as their
starting point for structuring governance arrangements. All of them create positions of doctors and
managers that are based on consensual decision making and common responsibility, in this way
structuring governance at hospital level and unit level. Interestingly, they consciously choose to
create ambiguous positions keeping formalization by rules and job descriptions low. Efficacy of dual
hospital governance depends heavily on personal strength, mutual understanding, and trust of the
incumbents, which offers new chances for governability but also harbours vulnerability to hospital
governance.
Introduction
- Governability: overall capacity for governance of the hospital, is expected to improve by putting
management of hospitals unambiguously in the hands of professional managers explicitly
wishing to get rid of the arena-like hospital governance system coupled with slow negotiating
processes of autonomous parties. The government rejects dual governance as a viable way to
improve hospital governability, stressing that modern hospital organizations operate in a market-
oriented healthcare system, “two captains on the ship” hinders the hospital's ability to compete.
Dutch governmental policy: get rid of ambiguity by establishing final responsibility of general
management.
- Hospital governance: a set of processes and tools related to decision making in steering the
totality of institutional activity, influencing most major aspects of organizational behaviour, and
recognizing the complex relationships between multiple stakeholders. However, hospital
governance is a complex problem because of two intermingling dynamics: The first dynamic is
internal and the second external.
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