Governance by ambivalence. The handling of quality control in the German hospital industry

This paper is dealing with regulation meant to formalize performance control in the German hospital industry. Against the background of quality assurance policies rolled out by both hospital managers and (quasi-)public... [ view full abstract ]

This paper is dealing with regulation meant to formalize performance control in the German hospital industry. Against the background of quality assurance policies rolled out by both hospital managers and (quasi-)public authorities, it discusses the paradoxes inherent to this regulation from a public management perspective. It is shown that, on the one hand, the German hospital industry exhibits a traditional network-based arrangement in which collective stakeholders collaborate in order to control (and im¬prove) organizational performance in terms of quality outcomes collectively while, on the other hand, this arrangement has increasingly become supplemented by provisions sti¬mulating interorganizational rivalry – which is an international trend (Cockson & Dawson 2012). Drawing on a recently completed research project and summarizing evidence from interviews with these stakeholders (providers, payers, regulators etc.), the paper expounds that such performance management is a fuzzy agenda lacking clear orientation. Relevant actors develop inconsistent concepts: The achievement of better health care results is approved as a common perspective yet quality control is meant to serve further aims: Major stakeholders want hospitals to outperform others (e.g. by certi¬ficates or high profile specialization) and to be funded on the basis of delivered results, with social insurance agencies being a driving force here (Bode 2010). Quality competition has become a common ‘lingua franca’ throughout the industry while stakeholders remain committed to negotiated solutions. Thus, there is ‘governance by ambivalence’: Facing problems with assuring universal quality in a context of increased competition, stakeholders handle the quality control agenda by claiming both ‘best service to all’ and regulation enabling hospitals to strive for exclusiveness. In terms of public administration theory, the case under study exemplifies pitfalls of a post-NPM configuration (in the sense of Laegreid and Christensen 2011) in which the idea to combine negotiated arrangements with quasi-market regulation leads into permanent states of ambivalence rather than in productive forms of health care governance.
Christensen, T. and P. Laegreid (2011). Complexity and Hybrid Public Administration—Theoretical and Empirical Challenges. Public Organisation Review 11(4): 407-423.
Bode, I. (2010). Towards Disorganised Governance in Public Service Provision? The Case of German Sickness Funds. International Journal of Public Administration 33(2): 172-181
Cookson, R. and D. Dawson (2012). Hospital Competition and Patient Choice in Publicy Funded Health Care, in: A. M. Jones (ed.), The Elgar Companion of Health Economics. 2nd edition. Cheltenham, Edward Elgar: 219-230.