Hälsobokslut! En drivkraft för förändrad verksamhetsstyrning? : En longitudinell studie av tre kommuners försök att minska sjukfrånvaron genom användningen av verksamhetsstyrningsmodeller

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No. 87

HÄLSOBOKSLUT! EN DRIVKRAFT FÖR FÖRÄNDRAD

VERKSAMHETSSTYRNING?

EN LONGITUDINELL STUDIE AV TRE KOMMUNERS FÖRSÖK ATT MINSKA SJUKFRÅNVARON GENOM ANVÄNDNINGEN AV

VERKSAMHETSSTYRNINGSMODELLER Arne Sjöblom 2010

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ISBN 978-91-86135-78-2

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ISBN 978-91-86135-78-2

Printed by Mälardalen University, Västerås, Sweden

Mälardalen University Press Dissertations No. 87

HÄLSOBOKSLUT! EN DRIVKRAFT FÖR FÖRÄNDRAD VERKSAMHETSSTYRNING? EN LONGITUDINELL STUDIE AV TRE KOMMUNERS FÖRSÖK ATT MINSKA SJUKFRÅNVARON

GENOM ANVÄNDNINGEN AV VERKSAMHETSSTYRNINGSMODELLER

Arne Sjöblom

Akademisk avhandling

som för avläggande av ekonomie doktorsexamen i industriell ekonomi och organisation vid Akademin för hållbar samhälls- och teknikutveckling kommer att offentligen försvaras

fredagen den 10 september, 2010, kl 13.15 i Beta, Mälardalens högskola, Västerås.

Fakultetsopponent: Docent Jan Lindvall, Uppsala universitet

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In the early 2000s the Swedish government financed a health statement project. This project aimed primarily to provide experience and knowledge of the usability of various management control models to function as health statement models. Furthermore, the project was expected to provide experience and knowledge of the supporting processes that was essential for the successful use of the selected management control models. The Ministry of Enterprise, Energy and Communications, which was the principal of the project, expected that the project would lead to the presentation of a common health statement model that could be used within the municipal sector.

The basis for this thesis consists of a longitudinal case study in which the health statement project was studied in three of the municipalities involved in the project. The investigation has made it possible to get four research questions answered: Was, and if so how, the management control systems within the municipalities changed by the introduction of health statements in each municipality? What initiated this change? How was the change in the management control systems achieved? What was the result of the changes of the management control systems within the three municipalities? By answering these research questions it has been possible to gain insight into how management control models have been affected in a change process.

The empirical material consists mainly of focus group interviews which have been supplemented by personal interviews and secondary data from three of the municipalities that participated in health statement project. The findings from the research can be observed in several areas. An organization's vision of itself in relation to similar organizations can determine whether a change process can be initiated. Individual forces, and especially stabilizing forces, are important to consider, and influence, if a change program shall be implemented. Institutional forces are linked not only to existing structures and individual forces are not only linked to individuals' actions. Both types of forces are affected by, and affect, modalities that exist as interfaces between structures and actions according to the structuring theory. Supporting processes are important to consider in relation to organizational learning and individuals' actions. Communication and motivational processes has been important as mobilizing supporting processes.

ISSN 1651-4238

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                                                                                                                                                                                                                  

Nyckelord: verksamhetsstyrning, ekonomistyrning, hälsobokslut, förändring, immateriella resurser, legitimering, drivkrafter, stödprocesser

Sjöblom, A. (2010). Hälsobokslut! En drivkraft för förändrad verksamhetsstyrning? Doktorsavhandling Nr.87, HST-akademin, Mälardalens högskola, Västerås. In the early 2000s the Swedish government financed a health statement project. This

project aimed primarily to provide experience and knowledge of the usability of various management control models to function as health statement models. Furthermore, the project was expected to provide experience and knowledge of the supporting processes that was essential for the successful use of the selected management control models. The Ministry of Enterprise, Energy and Communications, which was the principal of the project, expected that the project would lead to the presentation of a common health statement model that could be used within the municipal sector.

The basis for this thesis consists of a longitudinal case study in which the health statement project was studied in three of the municipalities involved in the project. The investigation has made it possible to get four research questions answered: Was, and if so how, the management control systems within the municipalities changed by the introduction of health statements in each municipality? What initiated this change? How was the change in the management control systems achieved? What was the result of the changes of the management control systems within the three municipalities? By answering these research questions it has been possible to gain insight into how management control models have been affected in a change process.

The empirical material consists mainly of focus group interviews which have been supplemented by personal interviews and secondary data from three of the municipalities that participated in health statement project. The findings from the research can be observed in several areas. An organization's vision of itself in relation to similar organizations can determine whether a change process can be initiated. Individual forces, and especially stabilizing forces, are important to consider, and influence, if a change program shall be implemented. Institutional forces are linked not only to existing structures and individual forces are not only linked to individuals' actions. Both types of forces are affected by, and affect, modalities that exist as interfaces between structures and actions according to the structuring theory. Supporting processes are important to consider in relation to organizational learning and individuals' actions. Communication and motivational processes has been important as mobilizing supporting processes.

ISSN 1651-4238

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                                                                                                                                                                                          

(7)

                                                                                                                                                                   

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Innehållsförteckning

1 Inledning... 1

2 Teoretiskt ramverk... 7

2.1 Ekonomistyrning... 7

2.2 Verksamhetsstyrning med fokus på immateriella resurser... 9

2.3 Prestationsmätning och legitimitet... 12

2.4 Struktureringsteori... 14

2.4.1 Struktureringsteorins delar... 18

2.5 Drivkrafter och stödprocesser vid förändringsprocesser ... 23

2.5.1 Drivkrafter ... 24

2.5.2 Stödprocesser... 27

2.6 Underlag för analys ... 30

3 Metod ... 33

3.1 Kunskapssyn och verklighetsuppfattning ... 33

3.2 Fallstudier... 34

3.2.1 Urval och undersökningens genomförande ... 35

3.3 Angående det teoretiska ramverket... 37

3.4 Undersökningsdesign... 39

3.4.1 Fokusgruppsintervjuer ... 40

3.4.2 Personliga intervjuer ... 44

3.4.3 Dokument ... 44

3.4.4 Alternativ metod... 44

3.5 Om analysen av det empiriska materialet ... 45

3.6 Avhandlingens kvalitet... 46

3.7 Sammanfattning ... 47

4 Hälsobokslutsprojektet ... 49

4.1 Det kommunala hälsobokslutsprojektet... 51

4.2 Avslutningen av hälsobokslutsprojektet... 58

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5.1 Styrningsproblem inom organisationen ... 65

5.2 Från välfärdsbokslut till hälsobokslut... 67

5.3 Ett delegerat arbete med hälsobokslutsprojektet - frihet under ansvar... 70

5.4 Ny chef för Tekniska kontoret – nya idéer om verksamhetsstyrning ... 71

5.5 Samordning för att finna gemensamma nyckeltal... 72

5.6 Mål- och resultatstyrning – kommunens balanserade styrning... 74

5.7 Åsikter om den nya verksamhetsstyrningen... 77

5.8 Hälsobokslutets integration i den balanserade styrningen ... 80

6 Hälsobokslutsprojektet i Mellanstad ... 85

6.1 Tydlig sjukfrånvaroproblematik kräver tydliga åtgärder ... 85

6.2 Hälsobokslutsprojektet, ett samordningsprojekt? ... 87

6.3 Det fanns en modell för att balansera den kommunala verksamheten … ... 89

6.4 … och i den modellen var medarbetarenkäten en viktig komponent... 91

6.5 Nyckeltalsanvändning – mätbarhet ger styrningsmöjligheter ... 93

6.6 Hur skulle den förbättrade balansen uppnås med hjälp av hälsobokslutsprojektet? ... 95

6.7 Den första redovisningen av kommunens hälsobokslut ... 99

6.8 De hälsobokslutsrapporter som publicerades efter projektets avslutning... 102

7 Hälsobokslutsprojektet i Sydstad... 105

7.1 Personalchefen initierar hälsobokslutsarbetet i Sydstads kommun... 105

7.2 Investors in People, ett underlag för analys och förändringsarbete... 108

7.3 Nyckeltal var viktiga, för att skapa uppmärksamhet ... 112

7.4 Ledningsorganisationen - i ”ständig förändring” ... 115

7.5 Hälsobokslutsprojektets utveckling – med allt mindre fokus på förändring.... 116

7.6 Förändrades någonting? ... 118

7.7 Nya försök att finna balans inom kommunen …... 119

7.8 … en balans som inte inkluderade ett hälsobokslut ... 121

8 Analys... 125

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8.1.1 Vad initierade kommunernas medverkan i hälsobokslutsprojektet? ... 125

8.1.2 Hur genomfördes förändringen av verksamhetsstyrningen i respektive kommun? ... 126

8.1.3 Hur påverkades verksamhetsstyrningen av införandet av hälsobokslut i respektive kommun?... 131

8.1.4 Vad fick förändringen av verksamhetsstyrningen för effekter i respektive kommun? ... 134

8.2 Analys av drivkrafter... 137

8.2.1 Institutionella förändringskrafter... 138

8.2.2 Institutionellt stabiliserande krafter... 140

8.2.3 Individuella förändringskrafter... 143

8.2.4 Individuellt stabiliserande krafter... 145

8.2.5 Sammanfattning av analys rörande drivkrafter ... 147

8.3 Analys av stödprocesser ... 149 8.3.1 Kommunikationsprocesser... 150 8.3.2 Rapporteringsprocesser ... 151 8.3.3 Utvärderingsprocesser... 152 8.3.4 Motivationsprocesser... 152 8.3.5 Kontraktsprocesser... 153

8.3.6 Sammanfattning av analys rörande stödprocesser... 154

8.4 Sammanfattning av analysen ... 155

9 Slutsatser ... 161

9.1 Drivkrafter som påverkar förändringen av verksamhetsstyrning... 162

9.2 Stödprocesser som påverkar förändringen av verksamhetsstyrning... 167

9.3 Framtida forskning... 169

Bilaga 1: Intervju- och samtalsförteckning ... 171

Bilaga 2: Förslag på hälsobokslutsmodell... 173

Bilaga 3: Ohälsotal per kommun... 175

Referenser... 176 

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Figur 1: Giddens första presentation av struktureringsteorins delar ... 18

Figur 2: Giddens andra presentation av struktureringsteorins delar ... 19

Figur 3: Egen tolkning av struktureringsteorins delar... 19

Figur 4: Integration av drivkrafter i struktureringsteorins delar... 27

Figur 5: Integration av stödprocesser i struktureringsteorins delar ... 30

Figur 6: Analysmodellen med utgångspunkt från struktureringsteorin ... 31

Figur 7: Balanserat styrkort för Nordstads kommuns (från budget för år 2005)... 76

Figur 8: "Styrverktyget" för Mellanstads kommun ... 90

Figur 9: Hälsobokslutsmodell för Mellanstads kommun... 100

Figur 10: Framgångsfaktorer i Mellanstads kommun... 100

Figur 11: Drivkrafter integrerade i struktureringsteorins delar... 138

Figur 12: Utvidgad integrering av institutionella drivkrafter i struktureringsteorins delar ... 143

Figur 13: Utvidgad integrering av individuella drivkrafter i struktureringsteorins delar ... 147

Figur 14: Utvidgad integrering av institutionella och individuella drivkrafter i struktureringsteorins delar ... 148

Figur 15: Stödprocessers integrering i struktureringsteorins delar... 150

Figur 16: Analysmodellen med utgångspunkt från struktureringsteorin ... 155

Figur 17: En sammanfattning av analysen enligt struktureringsteorin ... 160

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1 Inledning

                                                                                        _                                           _ _{}            _{} _{}  _{}

(14)

                                                                                                                  _                                                                                   _{}

(15)

                                                                                                                                                                                                                

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                                                                                                                                                                                                                                                