Making Hospitals Governable: Performativity and Institutional Work in Ranking Practices

• Published date: 01 April 2019
• DOI: 10.1177/0095399716680054
• Author: Roland Bal,Iris Wallenburg,Julia Quartz
• Date: 01 April 2019
• Subject Matter: Articles

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Administration & Society
2019, Vol. 51(4) 637 –663
Making Hospitals
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Performativity and
Institutional Work in
Ranking Practices
Iris Wallenburg1, Julia Quartz2, and Roland Bal1
Abstract
Rankings have become ubiquitous in public service settings. Although there
are high hopes that comparative analysis leads to improved processes and
outcomes, there is also a growing criticism of rankings as creating perverse
effects. In this article, we analyze how public service governance is affected
by rankings with a special focus on how, in what ways, and to what extent
organizations are made into governable entities as a response to rankings.
The article is based on a detailed ethnographic study in three Dutch hospitals,
using insights from actor–network theory and institutional work, combining
the concepts of performativity and institutional work.
Keywords
rankings, performativity, institutional work, actor–network theory,
materiality
Introduction
Hospital organizations are increasingly asked to provide clarity over and
account for their performance. As part of a much broader wave of transparency
1Erasmus University Rotterdam, The Netherlands
2Maastricht University, The Netherlands
Corresponding Author:
Roland Bal, Department of Health Policy and Management, Erasmus University Rotterdam,
P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
Email: r.bal@bmg.eur.nl

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Administration & Society 51(4)
and accountability, of what Michael Power (1997) has termed “the audit soci-
ety,” hospital performance is measured by the use of performance indicators,
rendering information about processes and care outcomes accessible and com-
parable. Performance league tables or “rankings” are a case in point.
Rankings are currently hotly debated in many public service industries
across the world (Black, 2015; de Rijcke, Wallenburg, Wouters, & Bal, 2016;
Saisana, d’Hombres, & Saltelli, 2011). Much is expected from an increasing
transparency of the performance of public services as performance data are
believed to enable consumer choice and to contribute to competition between
service providers. Health care is no exception to this, and in the Netherlands,
as in other countries, various hospital rankings coexist. With their appeal to
numerical comparison of hospital organizations, rankings have been taken up
by an increasing number of organizations, including (social) media and
patient organizations. Hospital rankings in the Netherlands are produced by
patient organizations, health insurers, and professional associations. In addi-
tion, two yearly rankings for hospitals are published by the national newspa-
per Algemeen Dagblad (AD) and the weekly magazine Elsevier. As such,
rankings have become an industry in their own right, with an increasing num-
ber of private organizations being active on the ranking market.
Although rankings are widely used, we have very little understanding of
how hospitals respond to them. In practice as well as in the wider literature
on performance measurement, most attention is paid to improving methods
of evaluation and the unintended effects of performance measurement in
spite of good intentions (Freeman, 2002). It is argued that rankings can give
rise to negative unintended consequences as scrutiny and surveillance inten-
sify and organizations become overly focused on metrics rather than the qual-
ity the metrics are intended to assess (Scott & Orlikowski, 2012). Yet, how
rankings and underlying indicators actually interact within organizational
practices, the kinds of (organizational) practices they produce, and how rank-
ings may impact on organizations’ governing abilities receive less attention.
Sauder and Espeland (2009), in a study on the rankings of law schools, have
shown that through surveillance and normalization, rankings shape the insti-
tutional practices of law schools, changing actors’ perceptions, expectations,
decisions, and actions. In a similar fashion, this article embarks on the actual
day-to-day practices in which hospitals engage to organize for rankings.
In this article, we aim to achieve in-depth insight in how rankings, as a
representation of the wider and increasingly important institutional logics of
the market and managerialism in health care (van de Bovenkamp, Stoopendaal,
& Bal, 2016), affect hospital organizations and the people who work in them
by examining and displaying the everyday organizational practices that are
enacted in hospitals, and how these impact upon hospitals’ governing

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Wallenburg et al.
639
abilities. We do so through a qualitative, comparative ethnographic study,
researching the ways in which rankings and their underlying performance
indicators influence quality and other policies and practices in three hospitals
in the Netherlands. We ask to what extent and in what ways rankings are actu-
ally being used within hospitals themselves to change the institutionalized
practices of doing quality work and to govern the accompanied relations
between actors within the hospital organization, focusing specifically on
management–professional interactions as these are key to hospital gover-
nance practices.
Theoretically, we draw on two literatures that, to our knowledge, have
been rarely linked but can produce valuable insights to how rankings actually
play out in hospital organizations: actor–network theory (ANT) and institu-
tional work. More specifically, we take from ANT the focus on the performa-
tivity of rankings and the emphasis on the work that is needed to make
rankings happen within organizational contexts (Callon, 1998; MacKenzie,
2009), as well as ANT’s focus on materiality (i.e., “non-human entities”;
Orlikowski & Scott, 2013). These theoretical insights enable us to point out
how indicators define content, shape reality, and transform hospitals in their
own image. However, we will argue, this transformation requires institutional
work (Lawrence & Suddaby, 2006; Lawrence, Suddaby, & Leca, 2011). The
notion of institutional work captures how social actors create, maintain, or
disrupt institutions (Currie, Lockett, Finn, Martin, & Warring, 2012;
Lawrence & Suddaby, 2006). In bringing ANT and institutional work litera-
tures together, we uncover that rankings “as such” may not necessarily
change daily activities and vested professional work practices, but they set
into motion the development of new governing tools that reconfigure both
work routines and relationships between actors and evoke new interdepen-
dencies between managers and health care practitioners as well as new lever-
age for management over professional domains. By analyzing ranking
practices in such a way, we not only attempt to shed light on the impact of
rankings on hospitals but also hope to contribute to a further development of
practice and material-based theories concerning institutional work (Jones,
Boxenbaum, & Anthony, 2013; Monteiro & Nicolini, 2015).
The main analytical questions guiding this research are how do hospitals
respond to rating and ranking practices, and with what consequences for the
governing abilities of hospital organizations?
This article proceeds as follows: First, we develop our theoretical frame
on the governance of performance, in which we connect ANT and institu-
tional work. Next, we present our methods, followed by our empirical find-
ings uncovering how rankings, through their underlying practices of
quantification, standardization, and commensuration, render clinical work

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Administration & Society 51(4)
accessible and manageable. We then show how the performativity of rank-
ings of making hospitals into governable entities is not an “automatic” pro-
cess, but is rather contingent and situated, requiring continuous work among
actors involved. We conclude by considering the implications for both theory
and practice.
Developing an Institutional Work/ANT Perspective on Governing
Performance
Studying governance practices in health care has a long tradition in the
sociology of professions, often focusing on the ways in which health care
professionals are governed by formal quality improvement systems. Those
studies have, for example, shown how professionals are able to “adapt”
quality systems to strengthen their own position (Currie, Humpreys,
Waring, & Rowley, 2009; Waring, 2007), leading to what some have called
“soft autonomy” (Levay & Waks, 2009). Waring (2007) points out how
doctors resist (external) managerial quality regulations through seeking to
subvert and “capture” components of the reform. As a result, he argues,
these regulations are internalized within medical practice and culture, lead-
ing to new forms of self-surveillance and self-management. Similarly,
Levay and Waks (2009) show how Swedish medical specialists have used
accreditation systems and registries to transform professional governance
while protecting the profession from outside pressures. These accounts,
however, tend to emphasize the abilities of professions to incorporate and
“repair” outside regulation (Micelotta & Washington, 2013), implicitly pre-
vailing the professional over the managerial account. It thereby overlooks
how professionals incorporate (external) surveillance mechanisms...