The interplay between central and sub-central levels: the development of a systemic standard based programme for governing medical performance in Denmark

This paper analyses the introduction of a systemic standards based programme for governing medical performance in Denmark. The programme combines clinical, organisational, and patient related standards and measures, and contains both external evaluation and self-assessment based on standards. The substance of the programme is new compared to the previous decentralised or professionally driven state of affairs that was based on a largely voluntary introduction of clinical standards, combined with a case-by-case evaluation of malpractice incidents. The programme strengthens hierarchy-based forms of governance; these co-exist with salient components of network-based governance as well as some elements of market-based governance. Institutional and contextual factors are important in explaining why a systemic standards based programme emerged as a result of the policy negotiation processes. In particular, the programme reflects stronger governance ambitions from the government in response to claims of a relative decline in the quality of the regional health services. However, the actual design is mediated by institutionalised negotiation processes among the state, decentralised authorities, and health professionals.