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Governance and strategy: exam summary
Week 1: what is governance?
With governance and strategy we include the outer context. The other
context influences the inner context and visa verse. In this course we focus on
the interaction between those two.
Three levels to approach governance and strategy – Example staff shortage
1. Macro-level: this level is about healthcare systems like: health policies, the role of patients and
citizens, the view on care and health, the role of professionals and patient associations. Role of
task substitution, introducing technology as a solution, role of volunteers and informal care givers.
2. Meso-level: this level is about what happens in healthcare organizations, health policies travel
downwards and shape the everyday reality of care organizations, the role of managers,
professionals, patients, municipalities, social care etc. Who bears clinical responsibility?
Complexities with implementing and using technology, professional boundaries etc. More about
how the stakeholders organize things.
3. Micro-level: this level is about the day-to-day interactions of individuals between professionals
and patients and between managers and professionals. New professional roles often rely on trust,
what do patients want, technologies embedded in existing routines.
From government to governance
Governance has a different meaning in macro, meso
and micro level. Essential is that it all got some kind
of steering element in it. When we think about
government we think about places of power where
decisions are made. However this power nowadays
has shifted a lot to other stakeholder in our society
who also have big responsibilities.
Hollowing out the state – Rhodes 2007
Rhodes introduces some core ideas in understanding
governance: policy networks, governance, core executive and hollowing out.
Policy networks: refers to sets of formal and informal institutional linkages between governmental
and other actors structured around shared interests in public policymaking an implementation.
Governance: refers to a new process of governing; or a changed condition of ordered rule; or the
new method by which society is governed. Governing with an through networks. Who does what?
Who has what resources?
Core executive: This mainstream analysis assumes the best way to look at the executive (uitvoerende
macht) is to look at key positions and their incumbents (betrokkenen).
Hollowing out: The ‘hollowing out of the state’ means simply that 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. So: less power for executive/state, horizontal relationships
between actors within network, steering of society (and organisations within society)
The Westminster model is a type of parliamentary system of government that incorporates a series
of procedures for operating a legislature, key aspects of which include an executive branch made up
,of members of the legislature (wetgevende macht), and that is responsible to the legislature; the
presence of parliamentary opposition parties; and a ceremonial head of state who is different from
the head of government.
Key concepts: cooperation & interdependency, autonomy and trust, government to governance.
Governance in operating room nursing – Riley 2005
Governance in this article is a social political aspect of the nurse-doctor relationship.
Foucauldian concept of governmentality: Foucault used the term ‘’governmentality’’ to combines
ideas about ‘’government’’, or the power to direct conduct, with the concept of ‘’mentality’’, or how
governing is thought about and approached.
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.
Nurses govern by controlling the practice environment and constructing collegial relationships.
Operating nurses can steer in the surgical room in 3 ways: technical knowledge of surgeons
(instruments), inscribing surgeons bodies in time (time; being late) and deep knowledge of surgeons
(when to approach or not the surgeon). Nurses’ knowledge govern the surgical room, knowledge is
power, with their knowledge they can steer in a certain direction
Structuring ambiguity in hospital governance – Scholten 2018
In this article governance is approached as a duality with multiple stakeholders: 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.
Dual hospital governance, the coexistence of managerial and professional lines of authority, can be
understood as a characteristic feature of hospital governance. “Peaceful coexistence” of the two
governance structures.
The article shows that achieving this dual governance contains of 4 building blocks:
1. Pragmatic collaboration: look and strive for workable and viable relationships between
actors.
2. Co-governance: structuring relevant positions and levelling the general board with medical
specialist, creating shared responsibilities and activities
3. Keep formalization and job descriptions low and letting norms, trust and mutual
understanding control behavior.
4. Making processes in the ambiguous positions ask for strong people, the positioning of
doctors and mangers at both levels implies the introduction of role conflict.
Developments in intergovernmental relations: towards multi-level governance – Peters 2001
Multi-level governance: collaborative exchanges and joint decision making between institutions at
different levels of the political system. This new concept is non-hierarchical, vertical but also
transnational and regional.
The role of governance is establishing collaboration between organizations on different levels
(transnational, national and local level). All these levels have different processes and all these
, processes interact with each other and these governance processes influence each other. Policy
change <> institutional change. Government agencies work together to steer society.
Week 2: Decentralisation of care
Hybrid governance in Dutch healthcare
Our governance system consists of four different domains, see the picture on
the right. This is being translated to the regulation of the healthcare system.
We have a tradition of private delivery of healthcare, and not in the
ownership of the governance. But they do deliver a public good
There are a few fundamental characteristics of Dutch healthcare:
Private delivery: hospitals are not owned by the government.
Professional autonomy: healthcare professional are autonomous in how they practice their
specialism. Of course they are also regulated by laws, organizational rules, but they have to take
professional decisions.
Public means held by private organizations: we don’t use tax money, but premia money. Here
you see the hybridity as well: public good but private finances and delivery
Huge government responsibilities, limited government power
There are also a few practical implications:
Inherent hybridity: commercial (citizen perspective) and guardian (protection of the government
for the people, collectivity). A mixture of individual responsibility and choice with collective
responsibility and solidarity
Variety of public-private partnerships and networks (national and local), also a lot of atonomy
Trends in governance
There are a few trends that we see in the Dutch hybrid governance.
Within the public domain (policy and politics) Within the civil society (community)
- More local government (decentralization) - Mobilization of networks: social networks like
- More supervision and control family, friends, neighborhood
- More international (EU) regulations: due to - Informal care provision
market regulations, competition regulations - Fragmentation of organizations
- Trust on basis of regulation - Trust on basis of loyalty and involvement: taking
care of each other
Within the private domain (market) Within the medical domain (profession)
- Regulated competition: contract based - More focus on transparency: we want to
- Market like management and instruments: New compare
Public Management, specialization etc. - Changing concepts of health and care:
- Trust in negotiation mechanism - Competition and cooperation: mixture
- Trust on basis of knowledge and professional
status
Decentralization: different kind of decentralization play a role – Saltman & Bankauskaite 2006
1. Political decentralization: shifting policy making responsibility from central to local levels.
Example: hospital care in Norway and Finland. First there was decentralization, but there was still a
large planning role for the state. Then there was re-centralization. It’s a `balancing act’ or `pendulum’.
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