Healthy measuring: The use of performance measures in the Swedish healthcare system

Sammanfattning: Ever since the rise of New Public Management in the 1970s, public sector performance management has been increasingly important around the world. Despite many critics, the use of performance measures (PMs) as a solution to measure the impact of reforms and public sector performance has increased especially in the healthcare sector. Scholars have investigated the design, implementation and impact of these PMs, but limited attention has been given to its use and its use in relation to the context of healthcare. Given that literature defines the healthcare sector as a loosely coupled system, the dynamics of the healthcare system was in this study further unpacked with the concept of loose coupling. Therefore, this study aimed to explore how the use of performance measures impacts the dynamics of the Swedish healthcare system. To answer this question, a multi-case study was conducted at three Swedish county councils. The study consisted of a quantitative pre-study and 18 qualitative interviews. The data was then analyzed based on a conceptual framework developed from the performance administration and healthcare policy literature in the context of loose coupling. The findings identified four key uses of PMs which differed across hierarchical levels, contributing to more tight relations between the elements of the system overall. The change in relations further impacts the organizational outcomes of loose coupling and subsequently the dynamics of the Swedish healthcare system making some aspects of the system easier to govern and more prone to behavioral change than before. This study contributes to the limited research on the use of PMs by unpacking the complex healthcare context through the concept of loose coupling.