A Service Management Perspective on Healthcare Improvement: Integrating Social Context

Doctoral thesis, 2016

The current dissertation argues that ideas from service research should be given a more prominent position in improving healthcare that is capable of managing current and future challenges. The integration and combination of intangible resources, such as knowledge and skills, constitute the service in this thesis; thus, service is conceived as a verb. A central notion in such conceptualization is value co-creation, implying that healthcare providers may only offer potential value, which is realized as real value by people in their broader lifeworlds. Consequently, the healthcare provider is often only one of many actors in the individual’s value-creation process – in which resources from a multiplicity of actors are integrated and combined. One challenge that is particularly addressed in this thesis is unsatisfying inhabitant/patient perceptions concerning how healthcare is executed. More specifically, this refers to interpersonal aspects, including interaction between inhabitant/patient and provider, access to adequate information, and prerequisites to actively participate in one’s own care. Another challenge addressed herein is disparities between groups in society. A mainstream service management perspective is deemed relevant in targeting the first challenge, with foci on the inhabitant’s/patient’s active role rather than the internal affairs of the organization; interaction rather than results; and providing a holistic view rather than treating healthcare in isolation. In order to face the second challenge of disparities between groups, I argue that it is necessary to explicitly integrate the social context, which is claimed to have been neglected in traditional service research. Such context includes not only a diversity of actors, but also societal structures that influence – and are influenced by – the healthcare meeting and thus the individual’s prerequisites to actively participate in her or his care. By adopting a moderate social constructionist position – which contrasts to the individualism characterized by mainstream service research – the focus of the thesis moves from singular to plural, from individual to groups in society. On one hand, in such a position, categorization of individuals into groups is not uncomplicated. On the other hand, healthcare improvements are enabled on a collective level. The constructionist position also permeates conceptions of knowledge: rather than an absolute “truth,” knowledge is about different perspectives. An extension of this reasoning is that healthcare needs to manage multiple perspectives to achieve improvement. Consequently, the purpose of this thesis is not to proclaim a service management perspective as a universal solution, but rather to enhance its position among a diversity of mutually complementing perspectives. The empirical material draws from three studies, discussed in five papers. The first study sought to increase knowledge of three groups’ perceptions on parenthood in a child health service context. The second study mainly addressed the reasons why men and women reported complaints in healthcare. The third study addressed how healthcare providers and community representatives could contribute to increased participation in a screening program in an area with a large number of foreign-born inhabitants. Cumulatively, the studies illuminate the potential of a service management perspective to improve healthcare, not least being the focus on the inhabitant’s/patient’s perceptions, but also their active role and the inclusion of actors in the individual’s broader lifeworld such as family members and the local community. In line with a service management perspective, the interactional aspects are argued to be important enablers for individuals to participate in healthcare. However, by integrating the social context, it is also revealed that interaction may also constitute a constrainer of possibilities for individuals or groups to be participative. A service perspective integrating social context also offers possibilities, not least by enriching the emerging field of improvement science. Through lifeworld-situated perceptions, in which groups’ perceptions beyond healthcare are identified, healthcare may be improved to better address group members’ needs given their broader life situations. Representative co-creation implies that a collective’s unique knowledge and skills are used productively in order to improve healthcare that manages diversified needs and expectations.