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Mellan kunskap och politik: Kvalitetssystem och offentlig kunskapsstyrning i hälso- och sjukvården
Linköping University, Department of Management and Engineering, Political Science. Linköping University, Faculty of Arts and Sciences.ORCID iD: 0000-0001-6803-7414
2016 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Between knowledge and politics : Quality management systems and public knowledge management in healthcare (English)
Abstract [sv]

Syftet med den här avhandlingen är att undersöka utvecklingen av kvalitetssystem i hälso- och sjukvården ur ett historiskt-institutionellt perspektiv utifrån fallstudier och konceptuella analyser. Särskilt analyseras implikationer av utvecklingen med avseende på relationen mellan den medicinska professionen och det politiskt administrativa systemet samt konsekvenser för den politiska styrningen av sjukvården.

Studien visar att medicinska kvalitetssystem och därmed även den medicinska professionen bäddats in i den politiska styrningen i takt med att ambitionerna mot en offentlig kunskapsstyrning tilltagit. Den visar även att hälso- och sjukvårdens kvalitetsregister i olika faser av sin utveckling har påverkats av politiska ideologier, managementidéer och idéer om transparens. Öppna jämförelser som en oavsiktlig konsekvens av kvalitetsregisteranvändningen förstärker dessutom tendensen mot en offentlig kunskapsstyrning.

Av studien framgår också att den offentliga kunskapsstyrningen utmanar föreställningen om demokratiidealet om upplyst förståelse. Den ökade fokuseringen på kunskapsstyrning inom hälso- och sjukvården gör det relevant att ställa frågan vem som styr vem i svensk hälso- och sjukvård, vilket i sig är en fråga om demokrati och legitimitet.

Abstract [en]

The aim with this thesis is to describe the quality development in Swedish healthcare from an institutional perspective, analyse implications of the development concerning the relationship between the medical profession and the public administrative system and discuss consequences for political direction and welfare organization. The study is based on four case studies and one conceptual analysis.

The main conclusion is that the medical quality systems have been imbedded in the political management alongside the development towards a public knowledge management. The analysis has more specifically uncovered that quality registries in healthcare have been influenced by political ideologies, management ideas and ideas of transparency. It is also clear that open comparisons were an ‘unintended consequence’ of the quality registry development that has enhanced the development towards a public knowledge management.

The analysis also shows that public knowledge management challenges the ideal of democratic enlightened understanding. The development of public knowledge management in the healthcare sector raises the question of who is governing whom in Swedish healthcare.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. , 81 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 690
Keyword [sv]
Offentlig förvaltning, hälso- och sjukvårdspolitik, historisk institutionalism, kvalitetsstyrning, kunskapsstyrning, Public administration, healthcare politics, historical institutionalism, quality management, knowledge management
National Category
Public Administration Studies Information Systems, Social aspects Social Sciences Interdisciplinary
Identifiers
URN: urn:nbn:se:liu:diva-130924DOI: 10.3384/diss.diva-130924ISBN: 9789176857199 (Print)OAI: oai:DiVA.org:liu-130924DiVA: diva2:956758
Public defence
2016-09-29, ACAS, Hus A, Campus Valla, Linköping, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2016-08-31 Created: 2016-08-31 Last updated: 2016-09-06Bibliographically approved
List of papers
1. Explaining Quality Management in the Danish and Swedish Public Health Sectors: Unintended Learning and Deliberate Co-Optation
Open this publication in new window or tab >>Explaining Quality Management in the Danish and Swedish Public Health Sectors: Unintended Learning and Deliberate Co-Optation
2016 (English)In: International Journal of Public Administration, ISSN 1532-4265Article in journal (Refereed) Epub ahead of print
Abstract [en]

This article examines the development of diverse quality systems in the otherwise quite similar Danish and Swedish public health sectors. After decades of numerous piecemeal medical and managerial quality development programs in both countries, a nationwide mandatory accreditation system was introduced in the Danish health services in 2009. Nationwide quality indicator projects are also found in Sweden, but there has been political attempt to introduce a compulsory system. This article seeks to explain this difference. It argues, first, that resistance from the medical professions blocked the introduction of compulsory, nationwide quality systems in both countries for decades. Second, the implementation of the Danish accreditation system was triggered by a combination of unintended policy learning produced by local reforms in two counties and of the Ministry of Health’s carefully orchestrated policy process that served to co-opt critical voices in the medical profession.

Place, publisher, year, edition, pages
Routledge, 2016
Keyword
Historical institutionalism; path dependency; policy learning; quality managment systems
National Category
Public Administration Studies
Identifiers
urn:nbn:se:liu:diva-128223 (URN)10.1080/01900692.2015.1064959 (DOI)
Available from: 2016-05-23 Created: 2016-05-23 Last updated: 2016-08-31Bibliographically approved
2. What frames Quality Registers in Swedish Health Care: an institutional approach
Open this publication in new window or tab >>What frames Quality Registers in Swedish Health Care: an institutional approach
2011 (English)In: Proceedings from 14th Uddevalla Symposium, 2011 Entrepreneurial Knowledge, Technology and Transformation of Regions / [ed] Iréne Bernhard, Linköping: Linköping University Electronic Press, 2011, 1-19 p.Conference paper (Other academic)
Abstract [en]

Quality issues strike the classical conflict in a democratic health-care deliverysystem of different interests among the politicians, the medical profession andpublic officials. This cannot be studied as a cut-off whiz. Quality registers havedeveloped over the past 40 years. Therefore, this paper puts the innovation ofquality registers in an institutional perspective. Two things are essential in thispaper. First, this paper reviews the emergence of quality registers in Swedish healthcare as an effect of institutional arrangements. Second, it analyses the interactionof diverse factors in different institutional settings and logics. The relevant data forthe study was collected from official/unofficial policy documents and key actorinterviews.The empirical findings show that three different waves of development can betraced in history that has highly affected the development of quality registers. Italso shows that medical quality is framed and determined by physicians in line withprofessional knowledge and by the primary institutional logic of quality in medicalcare. However, organisational quality in health care is framed by the logic ofpublic equity of access based on a third party payer and the logic of managerialcontrol. These two paths of quality developments are now federating in aninstitutional logic of transparency. The contribution of this paper is importantbecause it produces insights in different institutional logics, which frames the riseof the two quality paths and the problems they have to face in order to merge. It also enhances the existing knowledge that institutions matter.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011
Series
, Research Reports 2011:05 University West, ISSN 1653-7831 ; 2011:05
Keyword
health care, institutional change, quality, innovation
National Category
Public Administration Studies
Identifiers
urn:nbn:se:liu:diva-88746 (URN)978-91-977943-2-9 (ISBN)
Conference
14th Uddevalla Symposium, 2011 Entrepreneurial Knowledge, Technology and Transformation of Regions, June 16-18, Bergamo, Italy
Available from: 2013-02-19 Created: 2013-02-18 Last updated: 2016-08-31Bibliographically approved
3. Path Dependence on New Roads. Institutional Development of Quality Registers
Open this publication in new window or tab >>Path Dependence on New Roads. Institutional Development of Quality Registers
2014 (English)In: Offentlig Förvaltning. Scandinavian Journal of Public Administration, ISSN 2000-8058, E-ISSN 2001-3310, Vol. 18, no 2, 3-22 p.Article in journal (Refereed) Published
Abstract [en]

When explaining social development and changes in public administration, institutional changeis a typical focus. Institutional analysis can combine the analyses of changes on the basis offormal legal and informal arrangements; it commonly shows that institutions lead to inertiawhere changes over time are concerned. Political aims are a guide to how organizations aredesigned and governed. When goals and earlier decisions clearly guide change, path dependenceis a fundamental concept when explaining change. However, this analysis shows how andwhen quality registers appeared as an answer to changes in institutional arrangements in Swedishpublic healthcare. Through three phases, cumulative processes have been visible and theprocesses have been followed by an improved and increased usage of quality registers andother quality systems. This analysis shows that institutional development can be pathdependentin relation to methods and means. Despite changing goals over time, quality registersas a policy tool have been path-dependent and stayed firm. Thus, it is important to see alsoorganisational methods as a development path that can be used to implement even new policyaims.

Place, publisher, year, edition, pages
Förlag Göteborgs Universitet, 2014
Keyword
Institutional change, quality registers, public governance, path dependence, time
National Category
Public Administration Studies
Identifiers
urn:nbn:se:liu:diva-114514 (URN)
Available from: 2015-02-25 Created: 2015-02-25 Last updated: 2016-08-31Bibliographically approved
4. Policymaking through healthcare registries in Sweden
Open this publication in new window or tab >>Policymaking through healthcare registries in Sweden
2016 (English)In: Health Promotion International, ISSN 0957-4824, E-ISSN 1460-2245Article in journal (Refereed) Epub ahead of print
Abstract [en]

Healthcare registries, otherwise known in Sweden as national quality registries (NQRs), have progressed from being a patient-focused system supporting medical results to become the basis of a health policy steering instrument called regional comparisons (RCs). This article seeks to explain RCs as an unintended consequence of the NQR development, by utilizing the concepts of policy entrepreneurs and streams of impact: the problem stream (problem perceived), the policy stream (what is valid), and the political stream (governmental objectives). The empirical contribution lies in insights on how the RCs have developed as an unintended consequence of entrepreneurial deliberate action in the process of creating NQRs. These findings are based on documents, interviews, and previous research in the social sciences. The article also argues for a critical understanding of public knowledge management (PKM) related to experiences in the development of NQRs regarding how to use knowledge in healthcare government. This article highlights how knowledge generated in quality systems based on registries could imply a stronger role for authorities in exerting control over the medical profession. It also discusses the potential use of research evidence on NQRs as a base for more efficient policymaking.

Keyword
quality registries, stream coupling, policy entrepreneurs, public knowledge management
National Category
Political Science
Identifiers
urn:nbn:se:liu:diva-131037 (URN)10.1093/heapro/daw064 (DOI)27594141 (PubMedID)
Available from: 2016-09-06 Created: 2016-09-06 Last updated: 2016-09-12Bibliographically approved
5. Public quality – for whom and how? Integrating public core values with quality management
Open this publication in new window or tab >>Public quality – for whom and how? Integrating public core values with quality management
2015 (English)In: Total quality management and business excellence (Online), ISSN 1478-3363, E-ISSN 1478-3371Article in journal (Refereed) Epub ahead of print
Abstract [en]

Quality management (QM) plays an important role in public organisations’ efforts to create better access to, and effectiveness of, specific services. When transferring QM models from market-based firms to public services provided by public organisations, several basic contrasts and even contradictions must be addressed. Core values of the public sector differ from those of the private sector, but what are the consequences of this distinction? In this article we discuss the importance of four central arguments on public services: rights and access have to be considered; equality is an important facet of public services; coerciveness is a unique feature of public services; and legitimacy can be improved by high-quality services. These arguments have not been discussed explicitly in the context of QM. Adding these central aspects of public services to the QM field could generate more sustainable ways for developing quality and QM in public services in particular and the public sector in general.

Keyword
public sector; customer; citizen; quality management
National Category
Public Administration Studies
Identifiers
urn:nbn:se:liu:diva-128224 (URN)10.1080/14783363.2015.1087841 (DOI)
Available from: 2016-05-23 Created: 2016-05-23 Last updated: 2016-08-31Bibliographically approved

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