Together alone: Organizing integrated, patient-centered primary care in the layered institutional context of Dutch healthcare governance

We aim to better understand the dynamic between professionals and institutions by scrutinizing how professionals conduct institutional work in a layered institutional context. To date, institutional scholars have either studied professionals or institutions as objects of maintenance or change. Here, we suggest an alternative ‘relational’ and ‘evolutionary’ interpretation of the relation between institutions and professionals. We do so by introducing a two-dimensional analytical framework. We illustrate the relevance of this framework by analyzing a policy implementation program called ‘Primary Focus’. This program sought to improve the provision of integrated and patient-centered primary care by organizing multidisciplinary collaboration. Progressing through various forms of institutional work, we describe how professionals internalized the principles of ‘patient-centeredness’ and ‘multidisciplinary collaboration’ and set out to reach program objectives. We reveal that, while professional identities, roles, and positions were changing in the program, professional boundaries were reproduced. In the process, patient-centeredness turned from a shared objective into a contested professional quality. Consequently, the program did not lead to the new organizational formats that policy-makers had been aiming for. Our two-dimensional approach allows us to explain how this happened and why professionals had literally been working together alone.