Audit as Leviathan: Constructing Quality Registers in Swedish Health Care

• Published date: 01 November 2015
• Date: 01 November 2015
• Author: Elin K. Funck
• DOI: http://doi.org/10.1111/faam.12063

Financial Accountability & Management, 31(4), November 2015, 0267-4424

Audit as Leviathan: Constructing

Quality Registers in Swedish

Health Care

ELIN K. FUNCK∗

Abstract: This paper explores the rise of an audit practice: the national quality

registers in Swedish health care. Based on actor-network theory, the study tells the

story of an actor-network formed by physicians in the 1970s who mobilized themselves

around a common object; to develop the knowledge-base of medical professionals.

However, over time more actors became persuaded of the potential of the network

and associate themselves with it, resulting in reformed registers. The study shows

how the network develops into a macro-actor, a Leviathan in health care, how this

macro-actor comes to affect health care practices and how it contributes towards

maintaining a new governance regime.

Keywords: health care, New Public Management, measurements, actor-network

theory

INTRODUCTION

A number of studies have emphazised the transformation of the health care

sector during the last decades. New forms for checking and verification, such

as evidence-based medicine, clinical audit programmes, quality indicators and

financial models, have emerged. The introduction of New Public Management

(NPM) with new management ideas derived from the private industry alongside

an increased focus of systematization of medical practice and knowledge

has contributed substantially to this transformation (Hood, 1991 and 1995;

Christensen and Laegreid, 2002; and Lapsley, 2009). What the new management

∗The author is Associate Professor at the School of Business and Economics, Linnaeus

University, Sweden.

Address for correspondence: Elin K. Funck PhD, Associate Professor, School of Business

and Economics, Linnaeus University, SE-351 95 V¨

AXJ¨

O, Sweden.

e-mail: elin.funck@lnu.se

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2015 John Wiley & Sons Ltd 415

416 FUNCK

ideas have in common is that they all promise higher productivity and more

cost-efficient ways of organizing, controlling and delivering service (Ferlie et al.,

1996; and Christensen and Laegreid, 2002). At the same time, there is a general

agreement that the NPM inspired reforms are accompanied by greater attention

on detailed registration, measurement of results, and that actors outside the

medical profession both demand and attain more insight in and possibility to

control professional work processes (Hood, 1995; Vikkelsø, 2007; and Funck,

2009).

It has been argued that the new forms for checking and verification related

to NPM can in fact be seen as part of a larger audit explosion (Power, 1994

and 1997). Even though some studies have found that core medical practices

have been unaffected or only partially affected by the implementation of

new accounting tools (Lapsley, 1999; and Pettersen, 2001) other studies have

shown how the implementation of audit devices has transformed practices and

practitioners; resulting in hybrid professions (Kurunm¨

aki, 2004), colonization

and culture change (Skærbæk and Thorbjørnsen, 2007; Vikkelsø, 2007; and

Arnaboldi and Lapsley, 2008). Studies have even described the commitment to

reduce professional autonomy and strengthen the power of the public sector

auditors as a central feature of the audit society (Hood, 1995; Power, 1997;

Evetts, 2009; and Gendron et al., 2001 and 2007).

However, according to Power (1997) the audit explosion is more than a set

of techniques to describe and measure performance within an organization.

Techniques, such as registers, classifications and accounting, are always

intrinsically linked to ideas of wider societal programmes (Miller, 1994). The

reciprocity between programmes and technologies means that there is no

communal investment in the practice without a commitment to the idea and

the norms and hopes, which it embodies (Power, 1997, p.4). At the same time

the reciprocity is always temporary, fragile and localized (Miller and O’Leary,

1998). Technologies invented for one purpose may find their governmental

role for another (Miller and Rose, 1990, p. 11). Power (1994) points to

some underlying preconditions for the audit society. He argues that the most

influential dimension of the audit society is perhaps not the actual auditing

activities but instead the process by which the environment is made auditable

(Power, 1994, p. 8). Making things auditable is a deeply practical issue (Power,

1997). To become auditable implies that activities are rearranged so that they

can be monitored and documented, that quality criteria exist and can be agreed

upon, and that legitimate assessors have access to relevant data (Vikkelsø, 2007).

Yet, this focus, to understand the processes through which something is made

auditable, has been given little research attention (Vikkelsø, 2007; and Rocher,

2011). Analysing these transformations may not only shed light on the essential

features that have made possible the rise of the audit society. It may also add

important details to the understanding of the cluster of ideas that constitute

the programmatic aspect of NPM and to the understanding of why medical

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2015 John Wiley & Sons Ltd