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The gender subtext of public health care innovation: the case of implementing Clinical Microsystems in Sweden

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Longevity and improved medical remedies in combination with monetary limitations forces health care to increase its efficiency. This cannot be undertaken from a medical perspective alone, rather there is a call for innovative work practices (Berwick, Nolan and Whittington, 2008). Practices inspired by business or industry are thus implemented in Sweden as well as in other countries (Henriks & Berger, 2007; Leonard, Graham, & Bonacum, 2004). In addition to efficiency problems, Swedish health care has well documented gender inequalities. Women are consistently given care of lesser quality than men, and health care organizations typically have a patriarchal gender hierarchy, gendered professions, and stereotypical gender expectations, encompassed by both staff and patients (Smirthwaite, 2007; Upmark, Borg, & Alexandersson, 2007). The question for this paper is thus: will innovation in health care, designed to meet inefficiency problems, also address inequality problems? The particular model examined is labeled Clinical Microsystems, introduced by US scholars (Nelson, Batalden, & Godfrey, 2007) and implemented in several Swedish public health care organizations. The model borrows from Total Quality Management and from Lean Production. A Clinical Microsystem is comprised of the entire group of health care professionals that meet a patient. Patients and their relatives are considered integral parts of the microsystem, and so are material artifacts like computers and waiting rooms. The idea is that improvement of care emanates from better functioning microsystems engaged in constant quality development. The model holds thoughts of bottom-up processes, empowerment, multi-professional co-operation, and consensus. It focuses informal and social competences of staff, stressing change of attitudes, approaches, and measuring processes, and staff is evaluated on being collaborative, flexible and, not least, innovative (Berwick et al., 2008). From a feminist perspective, the model might have some unwanted side effects. It tends to produce a certain type of individual, and reproduce a certain social order. Norms of empowerment and consensus may give the illusion of a flat organization and a sense that influence is widely spread throughout the organization, but the influence is strictly conditional: in order for an individual to exercise influence, he/she must behave in a prescribed way and display the appropriate attitudes such as being collaborative and flexible (Powers, 2003; Orlikowski, 1991). Health care specialists have been accustomed to having a high level of control in their work, conferred by their professional training (Abernethy and Stoelwinder, 1995). Models that not only focus the end product but also the processes leading up it tend to restrict this autonomy. When professional authority is downplayed, this cannot be used a resource to challenge stereotyped gender expectations. When job descriptions include behavioral and social aspects, this tends to benefit the group that is in power (Krogstad et al., 2004), and as Eräsaari (2002) demonstrates, when formal rules and regulations are replaced by informal ones, and when organizations are flattened and made less bureaucratic, this tends to disfavor women. Barker (1993) suggest that team-organized work tends to stabilize norms rather than challenge them, and therefore, as Acker (2006) points out, may not reduce gender inequality at all. In conclusion, innovation in health care delivery such as Clinical Microsystems may change the delivery of care, but holds no clear promise of challenging gender inequalities in health care.