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In healthcare, organizational boundaries are often viewed as barriers to change. The purpose of this paper is to show how middle managers create inter-organizational change by doing boundary work: the dual act of redrawing boundaries and coordinating work in new ways.

Theoretically, the paper draws on the concept of boundary work from Science and Technology Studies. Empirically, the paper is based on an ethnographic investigation of middle managers that participate in a Dutch reform program across health, social care, and housing.

The findings show how middle managers create a sense of urgency for inter-organizational change by emphasizing “fragmented” service provision due to professional, sectoral, financial, and geographical boundaries. Rather than eradicating these boundaries, middle managers change the status quo gradually by redrawing composite boundaries. They use boundary objects and a boundary-transcending vocabulary emphasizing the need for societal gains that go beyond production targets of individual organizations. As a result, work is coordinated in new ways in neighborhood teams and professional expertise is being reconfigured.

Since boundary workers create incremental change, it is necessary to follow their work for a longer period to assess whether boundary work contributes to paradigm change.

Organizations should pay attention to conditions for boundary work, such as legitimacy of boundary workers and the availability of boundary spaces that function as communities of practice.

By shifting the focus from boundaries to boundary work, this paper gives valuable insights into “how” boundaries are redrawn and embodied in objects and language.

Dichotomous “gap” thinking about professionals and managers has important limits. The purpose of this paper is to study the specific ontology of “the gap” in which different forms of distances are defined.

In order to deepen the knowledge of the actual day-to-day tasks of Dutch healthcare executives an ethnographic study of the daily work of Dutch healthcare executives and an ontological exploration of the concept “gap” was provided. The study empirically investigates the meaning given to the concept of “distance” in healthcare governance practices.

The study reveals that healthcare executives have to fulfil a dual role of maintaining distance and creating proximity. Coping with different forms of distances seems to be an integral part of their work. They make use of four potential mechanisms to cope with distance in their healthcare organization practices.

The relationship between managers and professionals is often defined as a dichotomous gap. The findings in this research suggest a more dynamic picture of the relationship between managers and professionals than is currently present in literature. This study moves “beyond” the gap and investigates processes of distancing in-depth.

The purpose of this paper is to improve the general operationalization of an “active patient,” by examining the specific activities and skills expected of active patients.

Expected activities and necessary skills were studied through a qualitative case study into the development and use of an assistive technology (i.e. web site) aimed at stimulating active patient-ship. Interviews, observations and document analysis were used to capture and explore designers’ inscribing practices and their consequences regarding expected competences and activities of patients using the web site.

Designers inscribed two “co-design roles” that active patients were expected to perform on the web site (co-designing their own healthcare and co-designing the healthcare of peers), for which at least eight different competencies were needed. The absence of skills or facilities to apply these skills resulted in incomplete use, a different use than intended by designers and non-use of the web site.

Technological choices and inscribing processes determine who is able or facilitated to become active and who is not. Due to inscribed co-design roles, it also influences the extent to which already active peers are able to perform health-related activities. Different users with different conditions should be taken into account in the design as specific group characteristics can influence level of individual activity.

This study is, as far as the authors know, the first that examines the “active patient” concept by studying an assistive technology and using scripting literature, resulting in an improved understanding of what it means to become “active” in terms of skills and activities.