Numbering Care: Evaluative Metrics in Healthcare Governance

Run time: ongoing research line

Project description

This research line, that comprises various projects, addresses the increasing use of performance metrics (e.g. performance indicators, hospital rankings) in valuing performance in healthcare. In recent years, healthcare systems have grown into ‘big data houses’: numbers are collected and stored on all sorts of results, ranging from patient outcomes and professional performance to reimbursement data. Quantified data is expected to spur innovation, efficiency, and tailored care, and offers new possibilities to govern professional activities. However, critical studies of accounting have revealed numbers’ heterogeneous nature. Numbers are generated in one situation and complemented with other numbers and sliced and diced in new ways at other sites, leading to a continuous stream of new metrics and related governance practices. How do people (i.e. clinicians, policy makers, health insurers, mathematicians) make sense of these numbers, and to what purposes? What ‘stories’ to these numbers encompass, and how do such stories travel (or not) to other agencies that use these numerical results? For instance, a physician who scores badly on a certain aspect of care (e.g. waiting time for cancer treatment) but for good reasons (e.g. provide a young father to spend a bit of time with his children before starting chemotherapy treatment). Or, a different example; how does a central agency like Dutch Hospital Data (DHD) collects hospitals’ results on performance indicators to paint a picture of a hospital’s performance? What kinds of algorithmic processes and expertise does this involve?

We are interested in how numbers are ‘made’, ‘cared for’, ‘played with’, and how numbers travel between sites (e.g. the clinical work floor, the inspectorate, health insurers, a clinical registry), and what new practices of care they mobilize.


Iris Wallenburg, Roland Bal, in collaboration with Sarah de Rijcke (CWTS Leiden University), Björn Hammarfelt (CWTS Leiden University) , Anna Essén (Stockholm University, Sweden), Sam van Herwaarden.

The research comprises various collaborative projects

1. Together with CWTS Leiden University, we are interested in questions of (e)valuation of performance metrics, and how these metrics are ‘played with’ in everyday practice – as an alternative view for the often-used views on the disciplining effect of performance metrics on the one hand, and the power of the medical profession to withstand external control on the other.

We are organizing various conference tracks (4S 2018, Egos 2019) and publish on the topic:
De Rijcke, S., et al. (2016), 'Comparing comparisons. On rankings and accounting in hospitals and universities', in Mattering Press (ed.), Practising Comparison: Logics, Relations, Collaborations (Manchester: Mattering Press), 251-80.

Hammarfelt, B., et al. (2017), 'Advancing to the next level: the quantified self and the gamification of academic research through social networks'. Blog LSE

Wallenburg, I. and Bal, R. (2018), 'The gaming healthcare practitioner: How practices of datafication and gamification reconfigure care', Health Informatics Journal, Accepted for publication.

2. Together with the Free University Amsterdam and IQ Healthcare, we have conducted a research on the use of performance indicators by the Dutch Healthcare Inspectorate, showing how the Inspectorate anticipates the performative effects of indicators to steer on quality improvement in hospital care (2017-18).

Wallenburg, I., et al. (2018), 'Onderzoek naar risicoselectie met de basisset kwaliteitsindicatoren ziekenhuizen: op weg naar verantwoorde keuzes', (Amsterdam: Amsterdam Public Health).

3. Together with the University Utrecht (Judith van Erp) and Nivel (Cordula Wagner, Steffie van Schoten), and commissioned by the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZa) we have studied how physicians in the Netherlands perceive and the DRG system  , a finance scheme for reimbursing care(2016-17). (van Erp et al. 2018; van Schoten et al. 2016)

Van Schoten, S., et al. (2016), 'De medisch specialist en correct registreren: een onderzoek naar de beleving van medisch specialisten', (Utrecht: Nivel).

Van Erp, J., Wallenburg, I., and Bal, R. (2018), 'Performance regulation in a networked healthcare system: From cosmetic to institutionalized compliance ', Public Administration, Accepted for publication.

4. Drawing on this DRG research, we have further unraveled the ‘black box’ of the DRG system (together with Sam van Herwaarden and Joris Messelink), examining how finance schemes are experimentally used to govern healthcare.

Van Herwaarden, S., et al. (2018), 'Opening the black box of DRGs: Unpacking the technical remuneration structure of the Dutch DRG system', Health Economics Policy and Law, Accepted for publication.

5. Together with a group of Health Care Management (HCM) master students, we study the ‘quantified doctor/nurse’, exploring the role(s) quantification plays in professional work and professional identity (2017-18).

Ebbing, S. (2017), 'Is social media taking over healthcare?', (Erasmus University Rotterdam).

6. Earlier on, we have conducted a research on Dutch hospital rankings:

Bal, R., Quartz, J. , and Wallenburg, I. (2013), 'The performativity of rankings: on the organizational effects of hosptal league tables', (Rotterdam: institute of Health Policy and Management, Erasmus University Rotterdam).

Wallenburg, I., Quartz, J., and Bal, R. (2016), 'Making hospitals governable: performativity and institutional work in ranking practices', Administration & Society. DOI: 10.1177/0095399716680054