Ekonomisk styrning för förändring : en studie av ekonomiska styrinitiativ i hälso- och sjukvården

Sammanfattning: Since the end of the 1980’s  Swedish county council managers has been preoccupied with planning and implementing organisational change in order to alleviate the financial problems and to create more efficient production systems. Many of these efforts to change have implied changing the systems for management accounting and control, changes that have been inspired both by market-oriented ideologies and by the governance principles of large corporations in the private sector. Literature on manage­ment accounting and control indicates however, that management is unintentionally contributing to the creation of organisational inertia and conservatism. This contradiction is formulated as a change dilemma; ”How can managerial principles that make organizations subject to  bureaucratization and inertia be used as important strategies for organizational change?” The purpose of the study is thus to analyze the use of management control systems as organizational change strategies in health care, employing a change perspective on management control.When used as a change strategy,  management accounting and control becomes manifest as management control initiatives. Actors handle these control inititatives by organising themselves around the issue at hand. This organising process ends or fades away when there are no need for further attention to the control initiative.Empirical studies were made in the councils of Västerbotten, Sörmland and Upp­sala counties. Management control initiatives investigated were performance-related pay, quality improvement work, systematic planning procedures, provider/purchaser-models, downsizing projects and profit center systems.The systems for management accounting and control appeared to structure health care organisations in terms of spatial structuring temporal structuring and actor categorization. The management control initiatives introduced were structured as extraordinary organising processes delimited in terms of space, time and involved actors. Actors in the administrative norm system participated with the intention to change the organisation, while those in the medical norm system aimed at just handling the initiative.Management control initiatives can therefore be seen as passing opportunities to change, passing in the sense that the organising processes are temporary by nature, opportunities in the sense that temporary re-coupling can be used to  achieve long-term change. One such opportunity is the formulation of control initiatives; the possibility of using simple and standardized change strategies can be useful, but only if they are also linked to the medical norm system. A second opportunity is the temporary organising processes; if the project form of organising change can also be conveyed to the medical norm system, management control initiatives could result in short, intense courses of events that actually change things. The third opportunity  s the recurrent  cyc ica  pro­ perties  of  management  accounting  and control  systems, enabling  recurrent  activities around the same themes, thereby keeping them alive.