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1.
  • Berlin, Johan, 1975- (författare)
  • Beställarstyrning av hälso- och sjukvård : - Om människor, marginaler och miljoner
  • 2006
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • Inom hälso- och sjukvården har det länge varit svårt att styra verksamheten och dess resursförbrukning. När pengarna är slut i november kräver verksamheten mer resurser. För att enklare kunna styra och reglera sjukvårdens resursförbrukning införde flera av Sveriges landsting, under 1990-talet, beställarstyrning. Styrlogiken utgick ifrån att det som inte beställdes skulle heller inte utföras. Trots omfattande kritik har flera svenska landsting valt att behålla beställarstyrningen. I avhandlingen "Beställarstyrning av hälso- och sjukvård" har därför Johan Berlin undersökt hur och varför beställarstyrning utövas. Studiens resultat visar bland annat att beställarstyrning tillämpas genom att förtroende och kontroll kombineras, vilket gör det möjligt för betällarna att styra hälso- och sjukvården - på marginalen. I avhandlingen får läsaren en unik inblick i hur beställningsprocessen mot två sjukhus successivt växer fram. Här visas bland annat på förekomsten av ett "tyst kontrakt" mellan beställar- och utförartjänstemän i förhandlingsprocessen. Genom det tysta kontraktet kan beställarna ge sjukhusledningen mindre detaljerad uppföljning (ökad frihet) och i utbyte få dem att gå med på en snävare ekonomisk uppräkning av kommande års ersättning (sparande). I avhandlingen förklaras den fortsatta användningen av beställarstyrning med att den utgår från en ekonomisk logik. Det innebär att en kalkylerande relation lättare kan utövas mellan parterna. På så sätt kan den sista miljonen och det senaste byggnationsförslaget ifrågasättas. För de beställande tjänstemännen handlar det ytterst om att försöka hitta en acceptabel ekonomisk nivå och undvika problem snarare än att hitta den allra bästa lösningen. Den andra förklaringsfaktorn handlar om att det byggs upp ett administrativt mellanled (filter) mellan politik och profession. På så sätt kan vissa frågor "lagras" i tjänstemännens organisation i avvaktan på lämplig tid för genomförande. Sammantaget menar Johan Berlin att avhandlingen är viktig för den som är verksam inom sjukvården, särskilt de som arbetar med verksamhetens styrning, ledning och organisering.
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2.
  • Eriksson, Nomie (författare)
  • Friska vindar i sjukvården. Stöd och hinder vid förändringar i professionella organisationer
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • Implementation of decisions in professional organisations is characterized by the board making decisions for the professions to perform. In this thesis a decision concerning how process directed method of working in medical service is studied. The implementation was studied at two hospitals and units with similar medical alignment. Earlier research shows that medical service is hard to change. The aim with this study is to identify what supports and what hinders the professions’ implementation of a new working method and to explain why. The professions are registered nurses and physicians. They have good knowledge of the medical service and a great interest in good performance for patients as well as themselves. Characteristic is that they carry out decisions if they correspond with their norms and values which describe how medical service is to be performed, i.e. the institutions of medical service. Process directed method of working diverts from the traditional working methods in medical service. The activities in medical service are synchronized into a logical chain without repetitions. It gives a standardized medical service for all the patients included in one group of patients or one diagnosis. The new way of working changes what medical service is offered, where it is performed and by whom. The working method gives medical, as well as administrative, changes. Medically, questioning and changing alters the contents of medical service. Administratively, the medical service directing and organisation is changed. The overall view on medical service is developed with this working method, whether it is performed in one or several units. Established facts for the implementation of the working method is development of the dialogue, which is held between the professions, by real enthusiasts and offers from each hospital management respectively about education and stimuli. The professions’ satisfaction with the new working method also supports the change. Hindering the implementation of the method are activities such as rounds, reports and documentation and they are hard to adapt into the processes since they have developed into ceremonies that could wear traces of path dependence. On top of this there is a general expressed conception of lack of time, which also has developed into a ceremony. Despite that the study showed that existing institutions agree with the decided working method and the implementation is strong when it comes to available bases, the grade of implementation varies and problems of implementation are identified. If the organisation is marked by contentment, the existing working method will be preserved. If the decision is forced upon the professions they will re-form it or re-interpret it. If path dependent activities exist, only parts of the working method are changed which the professions’ experience as frustrating. However, if the professions participate in the implementation of process directed working method through dialogue, real enthusiasts and education and stimuli, the traditional working method will change.
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4.
  • Andersson, Johanna, 1981- (författare)
  • Locked-in collaboration
  • 2016
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • Collaboration, employed in defining a problem, finding a solution, and implementing it, has been proposed as a solution to a range of problems framed as wicked or complex. Collaboration can be justified based on instrumental, normative, and value-based reasoning. All approaches start in what collaboration is not: it is not demarcated, silo-based organization, but instead endeavours to achieve comprehensive and holistic perspectives and measures of service delivery. This has resulted in a great deal of research taking a normative and evaluative ap- proach to collaboration. In contrast, this thesis contributes to the growing critical stream of collaboration research. The overall aim of the thesis is to explain how collaboration has come to be a taken-for-granted solution and the possible consequences of this. The material was generated through a study of legally regulated inter- organizational collaboration (referred to by the acronym “FINSAM”) in the Swedish public sector implemented through local coordination associations. The coordination associations implement regulated collaboration between the Swe- dish National Employment Agency, the National Social Insurance Office, county councils, and municipal councils. Each local coordination association has a joint board and a pooled budget, which is to be used to finance measures targeting individuals in need of coordinated rehabilitation. The study was conducted through fieldwork in two local coordination associations, as well as in confer- ences and seminars addressing FINSAM in general. The findings indicate that collaboration in local coordination associations is organized in a project-like way alongside ordinary organizational practice. Two different approaches to organization were identified: the coordination association as either an actor or an arena. Depending on approach the coordination association will be more or less demarcated from ordinary organizational practice. De- marcation is strengthened through the construction of accountability. When local coordination associations are held accountable they are treated as hierarchical organizations with only vertical, but no horizontal, responsibilities. Horizontal practice and outcome are downplayed when accountability is constructed. The findings also indicate that the values attributed to this collaboration, together with its ordering narratives and its impact on legitimacy, create a dynamic result- ing in reduced need and latitude to problematize collaboration, which is taken for granted as the solution. This perceived decreased need for problematizing is connected to the pooled budget and the way the collaboration is understood: as something unique and better suited to handling the identified problems. The conclusion is that collaboration has become locked in within project-like organizations and organizing, and locked in as a solution through the rationalized myth of collaboration. The law governing FINSAM and specially allocated reources in pooled budgets strengthens this lock-in.
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5.
  • Carlström, Eric, 1957- (författare)
  • I skuggan av Ädel - integrering i kommunal vård och omsorg
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • The starting-point of this study is the subject of difficulties in integration. Is it possible to control the integration of occupational groups within an organization? To answer this question the welfare departments of four municipalities were examined. Two occupational groups were chosen by their overlapping tasks, long history and separated growth. These two groups, social welfare workers who peform home-help services, and trained nurses who perform homemedical care, have as an effect of legislation from one day to another been amalgamated in a common organization. This process too place in 1992 by a reform named "Ädelreformen". That year the municipalities in Sweden were directed to integrate home-help services with homemedical care. Social workers and nurses have, after the reform, in a common organization continued to represent different legislations and occupational traditions during the process of integration that began with "Ädelreformen". An exposition of studies on integration points out that integration is regarded as something good by legislators and managers but is often characterized by conflicts, especially between two parties with different occupational perspectives and overlapping areas. This study is focused on understanding management control promoting integration. Three types of control of special importance to this study are: need of resources, right of dispositions, and regulation. Integration is supported by a mutual need of resources between the subordinated parties. Need of resources occur when one party depends on another party for survival and growth. The right of disposition is resources protected by the executives. Such protection supports integration among the parties while the risk of exploiting and asymmetry are reduced. During conflict and differentiation a superior party, the executives, can contribute to stabilization by regulation. Regulation consists of rules from the superior party that state how the interchange of resources should be done between the subordinated parties. Four municipalities have been examined in order to answer the question of this study. Interviews were carried out in each municipality, with executives and subordinated parties, individually and in groups of staff, totally 28 interviews with 85 respondents in total. The four municipalities performed different types of management control. Those were neglect control, market control, partiality control and symmetrical control. Neglect control is when the executive lacks insight in the relation of the subordinated parties. The lack of insight contributes to an unregulated relation between the parties and weak rights of dispositions. The parties compete and claim the resources of the opposite party. Market control brings a strong need of resources to the subordinated parties. A purchaser-provider split allows the parties to accomplish resources by negotiations. Partiality control is when the executives support one of two subordinate parties. The weaker party is exploited by the opposite party. Symmetrical control implies secured rights of disposition. When symmetrical control is performed by the executives the mutual interchange between the parties is regulated. That prevents isolating and differentiating strategies. The result and the main contribution of this study is that management control matters and increases the possibilities of integration. When the executive establish distinct rules, strong rights of dispositions and need or resources, mutual interchange is promoted. Those three components in combination reinforce integration. The mutual interchange then repeated will make the integration grow stronger.
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8.
  • Ek, Emma, 1977- (författare)
  • De granskade. Om hur offentliga verksamheter görs granskningsbara
  • 2012
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • During recent decades audits have taken on a more prominent role in governance, in Sweden and in the Western world as a whole. Audit is used in this context as an umbrella designation for control methods such as inspection, auditing, evaluation, accreditation and certification. What these control methods have in common is that they entail external, (presumably) independent authorities or companies inspecting and assessing various phenomena. A number of auditing bodies scrutinise and provide assessments, and in so doing govern organisations at a distance. This dissertation is about audit in the making. It describes what takes place when operations are made the object of auditing and what happens in organisations while being audited. The question that is answered is: how is auditability achieved? In distinction from many other studies on audits, the auditees have a prominent position in answering this question. The auditing that is at the centre of the study is state inspection within schools and elderly care. In the dissertation episodes and events in the realisation of these audits are described. The analysis is based on ethnographically inspired fieldwork. Building on Miller and Rose’s perspective on governmentality, the study has as its starting-point the technologies and the varying contexts in which these are manifested: in reports, on websites, in everyday routines and meetings between the auditors and the auditees etc. The study shows that being the subject of audit requires extensive work. Auditability is achieved through a large portion of predictability where each step in the process is acknowledged. This predictability entails much more than providing advance notification of audits. It is a way of organising and executing the audit, where the auditees are not just a part of the object being audited, but also the extended arm of the audit authority. They supply the representations that the audit authority needs in order to describe and assess the operation. In achieving auditability the auditees do more than deliver information about the organisation. Auditability also entails making the audit meaningful and useful (it is for our benefit). This is done mainly by (re)interpreting the auditing as an educational opportunity which also normalises the process (it is nothing to be afraid of). Technically auditability is a question of how the object being audited and the benchmarks used are made comparable. The study shows that auditability is achieved through the construction of an object that is defined on the basis of benchmarks and is consequently comparable. In the audit studied there is no formalised report that can be e-mailed to the audit authority, printed out, submitted or put in an envelope. Rather, describing and defining the operation is an important aspect of auditing. The description is undertaken for a specific purpose, namely to act as underlying data for the assessment. It is therefore not surprising that the object and the benchmark are comparable, as the object is defined precisely for this purpose. What the study contributes to previous research is, firstly, bringing the auditees into the debate on how auditability is created. The study also contributes to a less static picture of how organisations are made receptive to auditing: that receptibility entails much more than installing systems that continuously supply the information about the organisation that the auditors need. The study also contributes to problematise the division into auditors and audited by showing that the boundaries are by no means always clear-cut. Finally the study shows that how auditability is achieved partially explains what is being auditable.
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9.
  • Erikson, Malgorzata, 1960- (författare)
  • Lokala politiska ledare - ett kollage av diskurser
  • 2004
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • In order to save what is left of the public trust in the political system, one of the most important tasks is to relegitimize the politicians. The general image of this group, the negative stereotypes and the lack of understanding of their complex duties, must be balanced, and the intention behind this study is to make a small contribution towards a more nuanced picture. The aim of the study is to try, through discourse analyses, to answer the questions: How do political leaders, i.e. members of the municipal executive committees, interpret their roles as politicians, including their relations with others and the circumstances under which they work? And which consequences do these interpretations have on their political practice and their status in society? A number of politicians in two Swedish municipalities have been interviewed, and I have observed on several occasions how these politicians interact in political meetings. It is the text constructed during these interviews and observations that represent the data collected for this study. In the dissertation I have consistently tried to carry three theoretical perspectives with me, perspectives that help me to sort my empirical findings and make them meaningful in a context outside my cases. The first of these three is the power incorporated in the discourses. From theories of freedom and structural oppression I have tried to find examples of how discourses limit our thoughts and how some groups benefit while others suffer. One of the main goals of my study has been to erase the oversimplified image of our politicians. But as it turns out, they are not afraid of creating stereotypes of their own, both of themselves, and - which is the second theoretical theme of the dissertation - of mass media. The third and final theme has been the alleged conflict between leadership and democracy. Theories of democracy and leadership are created by two different scientific disciplines, political science and organization and management studies, where the latter more often than not concentrates on the private sector. In the study I show how the ideals from a managerial discourse collides with a more traditional idealistic one, and how these two discourses are fighting each other, thus forcing the politicians to take sides. This is sometimes difficult since the battle is fought inside the head of individual politicians. I also try to point out how the discourse of organizational democracy slides between these two other discourse.
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10.
  • Fihn, Glenn, 1965- (författare)
  • Normer och reformer. Den landskommunala och stadskommunala budgetens och redovisningens historia 1862-1968
  • 2005
  • Doktorsavhandling (övrigt vetenskapligt)abstract
    • At the center of this study is the development of norms for the Swedish municipal budget and accounting in its historic context. By historic context, we refer here to the aspects of the course of history, which concern municipal expansion and institutional change. The study aims at describing and explaining how and why reforms were made in the norms for budget and accounting within the municipal sector of cities and rural municipalities during the period 1862-1968. Why and how budget and accounting reforms were made or, more precisely, which factors were behind the development of the norms for municipal budget and accounting, and whether regulation were put in place voluntarily or through state mandates, are the two queistions that are posed in the study. The reforms of the norms for budget and accounting which are studied more closely, are the proposals which were developed by the predecessors of the Swedish Association of Local Authorities, as well as the proposals for municipal financial statistics forms which Statistics Sweden developed until the 1960s. Based on previous research in the area, three hypotheses were formulated concerning how and why norms for the municipal budget and accounting change. The first one contained an assumption that the regulations around municipal finances and the norms for municipal budget and accounting follow the municipal expansion. The second one contained an assumption that the development of the design of the municipal budget and accounting system, occurs in an interaction between the state and the municipal levels. The third one contained an assumption that here was a difference in budget and accounting between the cities and the rural municipalities, but that these differences have been erased as the differences beween town and country disappeared. The study reveals that municipal expansion and institutional change have an impact on the development of norms for budget and accounting. The breakthrough of municipal business operations at the turn of century in 1900 and the periods of increased financing through borrowing and the accompanying attempts by the state to regulate the loan management were particularly important. The study also shows that the state and the municipalities through direct or indirect interaction have futhered the reforms of the norms of municipal budget and accounting. Finally it is shown that the difference between norms of the budget and accounting of cities and rural municipalities was reinforced until the 1940s only to be completely erased in a short period of time.
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