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  • Reflexive Standardization and

    Standardized Reflexivity

    Development and use of innovations

    in healthcare practices

    Esther van Loon

  • Reflexive Standardization and Standardized Reflexivity

    Development and use of innovations in healthcare practices

    Ontwikkeling en gebruik van innovaties in de gezondheidszorg


    ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam

    op gezag van de rector magnificus Prof.dr. H.A.P. Pols

    en volgens besluit van het College voor Promoties.

    De openbare verdediging zal plaatsvinden op

    woensdag 20 mei 2015 om 9.30 uur


    Esther van Loon

    geboren te Arnhem

    Reflexieve Standaardisering en Gestandaardiseerde Reflexiviteit

  • Promotiecommissie Promotor: Prof.dr. R.A. Bal Overige leden: Prof.dr. P.L. Meurs

    Prof.dr. N.E.J Oudshoorn Prof.dr. M.J. Schuurmans

    Copromotor: Dr. T. Zuiderent-Jerak

    Copyright 2015 © Esther van Loon

    ISBN: 978-90-809947-4-4

    Publisher: Uitgeverij Van Pommeren, Nijmegen

    Design and layout:

    Cover: Copyright 2015 front and chapter covers © Martijn Kolkman

    No part of this thesis may be reproduced, stored in a retrieval system or transmitted in

    any form or by any means without permission from the author or, when appropriate, from

    the publishers of the publications.

  • Contents

    Chapter 1 Introduction: on reflexive standards


    Chapter 2 Framing reflexivity in quality improvement devices in the

    care of older people


    Chapter 3 The nursing assistant of the future: attempts to improve

    elderly care organizations through professionalization


    Chapter 4 Diagnostic work through evidence-based guidelines: avoid-

    ing gaps between development and implementation of a

    guideline for problem behaviour in elderly care


    Chapter 5 Studying the interaction between design and use of

    healthcare technologies: the social learning perspective in a

    Dutch quality improvement collaborative programme


    Chapter 6 Uncertainty and the development of evidence-based guide-



    Chapter 7 Concluding remarks: reflections on reflexive standardization 165

    Summary 189

    Samenvatting 196

    Dankwoord 204

    Publication list 208

    About the author 209

  • Chapter 1

    Introduction: on reflexive standards

  • 8 |Chapter 1

  • Introduction: on reflective standards |9


    Introduction: on reflexive standards

    Nothing is permanent

    Crossing the metro station every day on my way to work in Rotterdam, I used to

    see this piece of graffiti. It says Niets is blijvend behalve verandering which means

    ‘Nothing is permanent except for change’. Then one day the graffiti was gone. It

    had been painted over, making the wall match the rest of the new grey interior of

    the station. Considering the point of the graffiti, that change is inevitable, the

    graffiti or rather its writer, would probably not have been bothered by being cov-

    ered in paint. Nothing is permanent, so chances are the grey will not last either.

    Sometime in the future, some new graffiti or other disturbance will likely emerge

    on that neat grey wall or will pop up in some other unexpected place.

    Painting the walls a uniform grey made the metro station look neat and

    tidy. Uniformity and neatness are probably seen as good things by those respon-

    sible for the changes at the metro. Graffiti, on the other hand, are probably seen


  • 10 |Chapter 1

    as unwanted expressions, legitimising the grey paint that made them disappear.

    However, what is good or unwanted cannot be attributed a priori to the phenom-

    ena of the world. Some graffiti are seen as a form of art1, which seems to make it

    ‘good’. Some uniformity is seen as boring, which seems to make it ‘bad’. We de-

    cide what is good or unwanted in situ. And, instead of being static, these decisions

    on variations change and evolve.

    This example of metro station graffiti raises fundamental points on the

    role and appreciation of variation, which forms the core of the investigation in this

    thesis. Here three concepts stand central: standardization, variation and reflexivi-

    ty. The rest of this chapter will explain their relation.

    (Un)wanted variation in healthcare

    Healthcare is inevitably confronted by many kinds of variation. For example, pa-

    tients have multiple conditions and wish specific treatment, influencing their care

    trajectory as this results in different options for treatment or diagnosis (Eddy,

    1984). Or different cultural backgrounds between the elderly admitted to nursing

    homes and their care givers result in communication differences (The, 2008). Or

    ranking hospitals to gain insight into the best shows substantial variation, depend-

    ing on who decides the order, the ranking criteria and the publisher, such as the

    Dutch opinion weekly Elsevier and the newspaper AD (Bal, 2014; Dijkstra &

    Harverkamp, 2012).

    Variation is found on all levels of healthcare and, as with the graffiti ex-

    ample, not all of it is either good or bad. Two dominant developments in

    healthcare, aimed at improving quality, seem on first sight to ‘stand for’ either

    good or unwanted variation. The first, the standardization movement seems

    mainly aimed at reducing unwanted variation, while the second, patient-centred

    care seeks to allow more individualized care and is likely to be associated with

    endorsing good variation.

    As I intend to show in this thesis, labelling variation as good or unwanted depends

    upon who perceives it in a particular context. The two developments of standardi-

    zation and patient-centred care do not a priori resemble either ‘unwanted’ or

    ‘good’ variation. In the rest of this section I will explain this proposition.

    Standardization in healthcare

    Over the last decades, standardization has become influential in care delivery. The

    need for standards emerged when societies became more complex and the divi-

  • Introduction: on reflective standards |11


    sion of goods and people crossed geographical borders (Timmermans & Berg,

    2003). The best-known example of standardized work practices, although not

    developed for care work, is probably ‘scientific management’, developed by Fred-

    erick Taylor. Workers were selected and trained to perform using standard meth-

    ods and processes so as to achieve optimal effectivity (Daft, 2006). Although sci-

    entific management seems to have lost much of its appeal, the ‘McDonaldization

    of society’ shows that similar ideas of uniformity and standardized processes are

    still popular mechanisms for organizing work in our societies today (Ritzer, 2000;

    Timmermans & Almeling, 2009). Standards in healthcare aim to describe the de-

    sired or minimal quality of care in evidence-based guidelines, protocols, decision-

    support (cf. Berg, 1997) quality norms and more. Objectivity, rationality and uni-

    formity are the key values in the thinking (Timmermans & Almeling, 2009; Tim-

    mermans & Berg, 2003; Zuiderent-Jerak, 2007b). Timmermans and Berg distin-

    guish four forms: design standards, terminological standards, performance stand-

    ards and procedural standards (Timmermans & Berg, 2003). The first is to ensure

    uniformity and mutual compatibility of systems. The second tries to ensure a uni-

    fied use of concepts, and the last two aim to intervene in healthcare practices by

    defining outcomes or processes. All of these ideal-type categories of standards

    aim to intervene in variation mainly by trying to reduce unwanted variation.

    The aim of standardization is to prevent subjective decision-making on pa-

    tient’s illness trajectories, which lead to differences in care delivery in similar set-

    tings. David Eddy explains:

    The plain fact is that many decisions made by physicians appear to be arbitrary – highly variable, with no obvious explanation. The very disturbing implication is that this arbitrariness represents, for at least some patients, suboptimal or even harmful care (Eddy, 1990, p. 287).

    According to Eddy, a consequence of decision-making differences is the possibility

    doing harm to patients, which can result in unequal access to or quality of care.

    John Wennberg has visualised this unwanted variation between care suppliers in

    many editions of the ‘Dartmouth Atlas of Care’2. Based on epidemiological re-

    search, Wennberg convincingly points at the variation in medical interventions for

    similar conditions throughout the USA. Such unwanted variation suggests misuse

    of care (Wennberg, 1984)


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