Working in an institutionally layered system on patient safety and quality

In many Western healthcare systems, market elements, such as patient choice and transparency, have been introduced. Dutch healthcare is a case in point. Here, a system of regulated competition was officially introduced in 2006. The introduction of the regulated market did not mean that other previously existing institutional arrangements to govern healthcare quality, such as professional self-regulation and top-down state regulation, have disappeared. Instead, these pre-existing arrangements have become incorporated in and conditioned by regulated markets. This process of adding institutional arrangements to the old can be described as one of institutional layerings. Institutional layering in healthcare means that increasingly complicated mixed arrangements to govern healthcare quality are introduced (Streeck and Thelen 2005). Since the institutional context of healthcare organisations impacts quality and safety work and power relations in the healthcare sector, it is important to study this context. More specifically, when this context becomes more complex because of layering, of which the consequences can be unpredictable, it is important to learn more about how institutional layering works out in healthcare practice.