The emphasis on person-centred nursing home care poses a key challenge for inspectors who regulate quality of care, because of its situated characteristics (i.e., for each client different and changing over time). This makes it difficult to assess with predetermined norms in contrast to for example requirements of medication safety. In this paper, we therefore empirically investigate how inspectors operationalize and evaluate open norms of person-centred care in the Dutch healthcare setting.

Qualitative methods were used to study the work of inspectors who assess the quality of nursing home care within the Dutch Health and Youth Care Inspectorate. The first author7it observed the inspection process of nursing home care organizations (preparation, inspection visit, consults between inspectors and team meetings) and conducted semi-structured interviews with the observed inspectors and managers of the assessed organizations. Furthermore, different versions of the quality report were analyzed.

Easy made operationalizations of person-centred care (e.g., choice for meal) received more attention than other, less easily made, operationalizations of person-centered care (e.g., group dynamics). The following three exclusion mechanisms show why certain aspects of person-centred care got less attention than others: 1) not being able to triangulate information 2) doubting the trustworthiness of a person 3) not being able to deviate from the structure of the inspection program. Furthermore, there are two exclusion mechanisms that show how the assessment of person-centred care is ignored or overruled by other values in the assessment framework: 1) downplaying person-centredness by mitigating circumstances and, 2) prioritization of safety risks over risks of lacking person-centredness.

In evaluating person-centred nursing home care using open norms, certain mechanisms are in place that exclude the assessment of quality of (certain aspects of) person-centered care. To overcome these mechanisms, a different, more reflexive approach for regulation might be needed to encourage stakeholders to engage in self-observation and self-criticism. Reflexive regulation using narrative methods can be especially helpful with complex issues, which are associated with uncertainty about standards and where different perspectives play a role. In further participative action research, we will experiment with and study the use of reflexive regulation using narrative methods in long-term care.