London 2001 Conference Abstracts: E.Bejerot

Eva Bejerot and Hans Hasselbladh

Quality systems in Swedish Health Services: Examination and confession technologies

National Institute for Working Life
School of Economics and Commercial Law
S-112 79 Stockholm Box 610, S- 40530 Gothenburg
Eva Bejerot e-mail
Hans Hasselbladh e-mail

A Swedish law was passed in 1996, which stipulated that appropriate quality systems should be introduced to ensure the quality of the health services. Total Quality Management systems has thus received a governmental sanction which contradicts the idea that it is a passing trend. Instead, quality systems may be seen as a central technology in the transformation of the health services in Sweden. The system has become the instrument that will guarantee quality in the services despite diminished funds and entrpeneurisation. During the 90's a number of quality models have developed and today there is a whole "tool-box" for quality control in the health services. In this paper we will describe the spread of the quality system in the Swedish health services on the basis of a questionnaire. The quality technologies are also discussed with references to Townely's work on confession and examination technologies and Power's work on "The Audit Society".

The spread of the quality system has been mapped out on the basis of a questionnaire study directed to administrative managers and heads of clinics in the Swedish health services. The investigation shows that 80 per cent of all clinics use at least one quality system and that the Swedish model, which corresponds to the American Malcolm Baldrige Award, is the one most commonly used. Managers and local enthusiasts have been of importance in the local spread of these systems, while trade union representatives have hardly been involved at all. Obviously quality has not been seen as anything that challenges professional autonomy, conditions of work or other important union questions. The replies to the questionnaire suggest, however, that there is a broad span regarding views on how well quality systems such as the Malcolm Baldrige Award function in the health services. Discussion on the advantages and disadvantages of the quality system are, however, absent. Possibly this is because the quality system thrives on rhetoric of common good, value for money and continuous improvement, values which can hardly be questioned.

In the "tool-box" for quality management there are several types of tools, which may be categorised in a few main groups: a diagnosis system for management, pedagogic models for staff members, and various methods for the production of measures and key numbers. At present there is an intensive development of national computer bases for key numbers, data which will be presented on Internet so that citizens, politicians, managers and staff will be able to compare the results obtained by clinics, hospitals etc. This technology is legitimated as being an instrument for customers' choice, but may also be seen as a technology of examination and shame, where those with the lowest key numbers are pilloried in public. Other technologies in quality systems are techniques that may be characterised as a collective confession-technology, and also standardisation of services, an important part of a comodification process, which enables market solutions, partial privatisation and out-sourcing in health care.


Townley B. Foucault, power/knowledge, and it�s relevance for human resource management. Academy of Management Review 1993:18; 3, 518-545.

Power M. The audit society: Rituals of verification. Oxford University Press 1997.