Description
The term quality management has a specific meaning within many business sectors. This specific definition, which does not aim to assure 'good quality' by the more general definition, but rather to ensure that an organization or product is consistent, can be considered to have four main components: quality planning, quality control, quality assurance and quality improvement.
Research Reports on Contextualization of Human Resource and Quality Management
A sense making perspective on everybody's involvement
Abstract
The principal idea of this paper is that human resource management (HRM) and quality management (QM) ideas require contextualization when used to change organizations. Here, contextualization stands for the process that leads to a shared meaning, i.e. that the majority of the co-workers in an organization understand and define a concept or change in terms that are shared and accepted. In the present paper, we study a strategic change project, based on HRM and QM ideas, conducted at the County Council of Värmland (CCV), the public healthcare authority in the County of Värmland in Sweden, where the focus was on everybody's involvement. Our interpretation of the project shows that a shared meaning of the concept of everybody's involvement was not reached in this particular case; i.e. contextualization did not occur. One important result of the study is that contextualization is a prerequisite for realizing HRM and QM thoughts. The paper also stresses how important it is that general and "non-contextualized" HRM and QM ideas is adapted to local practices when used to direct organizational change.
Keywords: Contextualization, Sensemaking, Human Resource Management, Quality Management, Everybody's involvement, Health care.
Introduction
Human Resource Management - HRM - and Quality Management - QM - have much in common. As an example, both disciplines address the importance of the empowerment of employees through everybody's involvement in strategic change processes in order to gain employee and customer satisfaction and increased effectiveness (Beer and Spector, 1985; Beer et al., 1985; Crosby, 1979; Deming, 1986; Juran, 1988). However, the effects of HRM and QM practices have been much debated. In the HRM context, research has found that empowerment programs do not deliver what they promise (Argyris, 1998; Edwards and Collinson, 2002; Hales, 2000). Explanations to the lack of positive effects have emphasized that junior managers, compared to senior management, have a more pragmatic and contextdependent interpretation of empowerment (Hales, 2000) and "?that managers do not expect as much from the term as some of the hype may have suggested" (Edwards and Collinson, 2002:294). In the QM context, research has also found that practices of QM, such as process and customer orientation, fail to materialize (Skålén, 2002; Skålén, 2004; Yong and Wilkinson, 1999). One reason often given is weak managerial commitment (Hales, 1991; Yong and Wilkinson, 1999), another is the internal power structure (Skålén, 2004).
We embrace the reasons given in previous research to the failure of HRM and QM practices, but in the present paper we like to make two further arguments. Firstly, the prevalent theories of organizational development in the HRM and QM context are rooted in the prescriptive and positivistic tradition (Beer and Spector, 1985; Beer et al., 1985; Crosby, 1979; Deming, 1986; Juran, 1988). In spite of their ineffectiveness no alternative to these models have been presented. The ambition of the present paper is to suggest an alternative view. Secondly, we like to base our alternative on the assumption that the ideas compromising HRM and QM can be described as non-contextual and general in nature; they are designed to suit any type of
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organization (Neergaard, 2002; Rövik, 2000; Townley, 2002; Wilkinsson et al., 1998). In support of our claim Edwards and Collinson (2002:286) have shown that the middle managers they interviewed expressed "?considerable ambiguity, even confusion, regarding the meaning of empowerment?".
With our standpoint in theories on organizational sensemaking (Weick, 1979; 1995), we argue that it is sometimes difficult for employees to understand and make sense of the somewhat general ideas that HRM and QM stand for. The organizational practice rests on institutionalized structures and processes (Bourdieu, 1977). This can mean that ideas which are new to the organization can be difficult to implement since the logic of the "world of ideas" and the "world of practice" sometimes differs (Brunsson, 1993). Thus, it can be difficult to apply HRM and QM ideas directly to an organizational practice, which is why a translation process is needed (Latour, 1987) - an adaptation to local conditions - in order to make the ideas understandable in the specific environment. This translation process, from idea to practice, we call contextualization. The need for contextualization and translation has been noted before in research into organizational change in general (Czarniawska and Joerges, 1996; Rövik, 2000), but the concept has been weakly elaborated in a HRM and QM context.
In the present paper, we will study the contextualization of everybody's involvement at the County Council of Värmland (CCV), which is the public healthcare authority in the County of Värmland (Sweden), where an extensive organizational development project, called CCV 2002, was initiated in 1998. The importance of everybody's involvement in change processes have been argued for both in the HRM context, especially within the empowerment debate (Edwards and Collinson, 2002), as well as in the QM context (Edvardsson, 1996a, b). From HRM quarters it has also been argued that Total Quality Management is likely to
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institutionalize the employee participation and involvement that quality circles failed to do in the 1980s (Hill, 1991; 1995). "TQM has the potential to align reality with rhetoric by means of participation" (Hill, 1991:561). It is clear that the CCV 2002 was inspired both by HRM and QM ideas, since the goals were satisfied citizens, satisfied coworkers and a balanced economy. Also, explicit reference was made to both disciplines by informants to the research presented in this paper. We have chosen to focus on everybody's involvement at the CCV from a sensemaking perspective. What is meant by everybody's involvement has not been well defined in previous research. The concept has neither an explicit nor a commonly accepted content. We have chosen to use the CCV's own definition in the documentation of their organizational development.
The main objective of the paper is to add precision and sharpness to the concept of contextualization and to clarify how contextualization is realized, or not realized. Since, at least, quality improvement work is said to be an excellent context for the study of sensemaking (Weick, 2000), a secondary objective is to introduce an analytical distinction between semantic and normative sensemaking in order to advance the knowledge of organizational sensemaking in theory and practice.
The paper is structured as follows. We begin with a review of Weick's theory on sensemaking (Weick, 1979; 1995), i.e. the theory we used to study the contextualization of the concept of everybody's involvement at the CCV. Next comes the interpretative methodology of the paper and a review of the methods used to collect and structure the empirical material. An empirical section divided into two themes follows - one regarding the very idea of everybody's involvement at the CCV and one on the practical strategic change work. After the empirical part, there follows an interpretative section wherein the empirical material is
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seen and understood from a sensemaking perspective. Finally, we discuss what implications the paper has for research and practice of HRM and QM.
Contextualization as sensemaking
In this section, we introduce the theoretical perspective that we use to explain and understand (Ricoeur, 1993), and to define contextualization and a lack of the same. Our perspective is based on Weick's theory of sensemaking (Weick, 1979; 1995), which is well suited to the interpretation and analysis of how local common conceptions develop, or do not develop, in an organization (Quist, 2003; Skålén, 2002). Sensemaking regarding everybody's involvement, in the present paper, constitutes a "measurement" of the degree of contextualization at the CCV.
Individual sensemaking There is a difference between experiencing something new and experiencing something a second time. For instance, there is a major difference in doing the weekly shopping in a grocery store for the very first time compared to going to one's usual store. In stores we are familiar with, our shopping is done more or less automatically, while shopping in unfamiliar surroundings requires an effort in order to come away with the necessary items in one's bags. Weick (1995) explains this with the help of the concepts of cognitive frame and cue, and the connection between them. An individual has a cognitive frame within which he or she has put together a list of actions relating to grocery shopping. Even as one is leaving home, this action list is set in motion and helps the shopper understand the upcoming events, recommending suitable alternatives as regards how to handle them. With the help of this list one can, for example, on one's way through the store, become aware that there is no bread in the shopping cart (a cue). One knows that bread is always needed and that by now it should be in the cart,
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since the bread section is located just inside the entrance. Realizing this, the individual can quickly decide what mode of action to choose in order to get the bread with the least possible effort. Without such a detailed list of action schemes, for example when shopping in an unfamiliar store, one cannot, from the items in the shopping cart, make the same kind of sense. When a cue is set in a cognitive frame, it can make sense all together - which can be seen as a concentrate of the concept of sensemaking on an individual level.
Sensemaking, however, is not comparable to the interpretation of extracted cues. Sensemaking is about "reading" the "text" as well as "writing" it. Weick (1995) argues, hence, that individuals actively create the environment they extract cues from; they "?produce part of the environment they face" (p. 30). He introduces enacted environment to describe the result of the process of creating an environment. Environments are enacted when something surprising or unusual happens, for example when a reform program is introduced in an organization, and provides the starting point for sensemaking. The enactment of reality is informed by the cognitive frames, since the latter have an impact on the actions taken, which in turn creates the response perceived. It is thus probable that the same shopper creates different meanings from similar events happening on two different days. When forgetting the bread, for example, the shopper might buy bread on one shopping occasion but not on the next. Instead, he/she may decide to buy yeast and wheat flour in order to bake when back at home.
As is evident from the shopping example, sensemaking works retrospectively; it is driven by history. Previous experience and actions are the building blocks of the cognitive frames (Weick, 1979). By comparing flows of events faced with past experience, people make sense of that flow. If one grocery shopper has experience of grocery shopping in Shanghai and another of shopping in London, their shopping behavior when moving to New York will be different. But it must also be noted that the actual context of the sensemaking event has a great impact on what cognitive frames are applied in order to extract cues from the enacted environment and how, and with which result, the cues are interpreted (Weick, 1995). 5
Shopping in Chinatown in New York might not be that different than shopping in Shanghai after all.
Collective organizational sensemaking How can individuals' sensemaking be of such great interest to those who want to study organizations? Is collective sensemaking possible? Weick (1995) takes his point of departure in Wiley (1988) when reasoning about sensemaking above the subjective individual level. What is called shared meaning in the present paper (cf. generic subjectivity, Weick, 1995) refers to the possibility that most individuals in an organization formulate identical, or at least similar, meanings regarding an event or a new concept. If shared meaning is formulated within the CCV on the concept of everybody's involvement, we interpret this as contextualization - the idea and the world of practice have entered into symbiosis. 1 Its counterpart we call fragmentary meaning2, which means that the individual's sensemaking in an organization with regard to a change or a concept, in our case everybody's involvement, differs. Fragmentary meaning is ranked as failed contextualization. We claim that, with contextualization, a common definition of reality will be reached, which is a prerequisite for change of practice. On the other hand, failed contextualization will cause antagonism between actors who have different definitions of reality and who will additionally prevent a change of practice. Consequently, shared meaning/contextualization should be the purpose of the change program at the CCV, as in other organizations.3
Somewhat simply stated, shared meaning requires the individuals to jointly extract and closely examine the cue in order to come to an agreement about its meaning. They need to formulate similar answers to the question: What is actually happening? It requires the individual's cognitive frames about this cue to be relatively homogeneous, which is dependent on the similarity of the enacted environments and a similar interpretation of the 6
context and organizational history being reached. The reason for fragmentary meaning can, for instance, be the opposite, i.e. that the individuals do not extract the cue at all, that they have heterogeneous cognitive frames, or that the enacted environments differ substantially. Within a large organization such as the CCV, it is possible to distinguish several smaller groups. In our interpretation, we will demonstrate how the differences between various smaller groups build fragmentary meanings, as seen in the perspective of the whole group.
An interpretation of the collective sensemaking in an organization is built on the sensemaking on the individual level. Two interesting questions emerge during the individual phase of the interpretation: Do the individuals extract the cue? What meaning is created from the cognitive frame(s) in use? The interpretation then turns to the collective level, and the main question is whether the meaning is shared or fragmentary. To what extent is the sensemaking shared? In order to answer that question, i.e. to understand if contextualization is achieved or not, we make a distinction between semantic and normative sensemaking. Semantic sensemaking refers to how individuals define or understand a word or concept. If the employees of the CCV express similar opinions about everybody's involvement , we interpret that as a sign of shared meaning, whereas if opinions differ, then sensemaking is characterized as fragmentary. With normative sensemaking, we mean whether a certain initiative to change the organization is considered desirable or undesirable, as well as whether the actors perceive the practice that such an initiative generates in positive or negative terms. In the present paper, this part of the interpretation deals with the question of whether everybody's involvement by the employees of the CCV was considered recommendable or not, and what possible positive or negative consequences this entailed in the world of practice. If the employees believed that everybody's involvement was to be recommended, and if they felt that it turned out well in practice, this is a sign of shared meaning. If, however, everybody's involvement as an idea
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and practice was perceived as something undesirable, this will be interpreted as a sign of the contrary, namely fragmentary meaning.
Sensegiving Another central concept in the theory on sensemaking is sensegiving. Smircich and Morgan (1982) write about the "Management of meaning", presupposing that management is a social process defined through the interaction between leader and follower. Their description of the phenomenon of management includes the task of defining reality in a way that seems sensible to those who are being led, who themselves have relinquished their right to interpret and define organizational reality. According to the authors, this process creates common reference points as a basis for organizational action. Management cannot expect shared meaning to emerge on its own, but should attempt to influence and facilitate the employees' sensemaking. Gioia and Chittipeddi (1991) and Gioia et al., (1994) have observed in their studies the relationship between the individual's own sensemaking and how that of others influences them. They coin the concept "sensegiving" to explain the processes that arise when someone attempts to influence somebody else's sensemaking. The dialectic relationship between making sense by oneself, as opposed to influencing other people's sensemaking, is also an important part of the concept of sensegiving. It is not as simple as first making sense for oneself and then trying to sway others; while an individual is influencing others, his/her own sensemaking is being affected as well.
Methodology and method
In the field of organization theory, a distinction is often made between functionalistic and interpretative methodology (Burrell and Morgan, 1979). Research into HRM and QM often relates to the former category. However, the present paper rests on an interpretative
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methodology (Alvesson and Sköldberg, 2000) and a social constructionist world-view (Berger and Luckmann, 1967). In our paper, the empirical level (Alvesson and Sköldberg, 2000) emerges as a story in several parts about the change program at CCV in general an everybody's involvement in particular. The criterion for truth in interpretative methodology is built on the argumentation in the stories presented (Czarniawska, 1999). The task of the researcher, then, is to present a dialectic communication between the presented story and the interpretative framework (theory) from which the interpretation finds its argumentation for a credible, i.e. rich in point (Alvesson and Sköldberg, 2000), interpretation.
In order to find material for the empirical story, we studied the change program labeled CCV 2002. The empirical study lasted approximately two and a half years (from the fall of 1998 until the beginning of 2001). We used a number of "techniques" - interviews, participant observation, and document studies. Altogether, 37 unstructured interviews (Silverman, 1993) were carried out which lasted between 40 minutes and two hours. The interviews can be described as conversations about the change program with CCV employees, mostly administrators, doctors, and nurses. 4 The respondents were selected from those who participated actively in the CCV 2002. An even distribution of gender and co-workers from the various personnel categories was aimed at. In addition to interviews, we carried out two months of participant observation of meetings regarding CCV 2002. The occasions we observed were selected because they were important as regards the progress and development of the change program. In addition to this, we studied everything written in the daily press from 1990 to 2000 about the CCV (approximately 25 folders of material), as well as internal documentation of organizational development which had taken place during the same time period.
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The empirical material was structured with the help of Silverman's (1993) Membership Categorization Analysis (MCA) technique. Accordingly, we arranged the material in three categories, i.e. pertaining to doctors, nurses and administrators. The next step in the structuring process was to arrange these into main categories, a process called the Membership Categorization Device (MCD). Silverman (1993) lists a number of rules governing how MCD is to be constructed. The purpose of the rules is to help group the individuals so that those who are bonded by common views are placed in the same Membership Category.5 The MCD analysis resulted in the formation of two main categories the new management and the rest of the employees - since these showed different attitudes towards everybody's involvement during the initiation of the CCV 2002. The new management was the driving force; the rest of the employees were passive and, in certain cases, vaguely unsympathetic. Considering that the primary ambition of the present paper is to study the emergence/absence of contextualization/shared sensemaking, we regard MCA to be the most sufficient method to use when structuring the material, especially - as was clearly explained in the previous section - since our interpretation of the sensemaking will concentrate on whether or not a shared meaning was created within the organization. If the various action groups that emerged during the process did not form similar meanings, contextualization failed.
Empirical story
This section presents the empirical story of the change program at the CCV, focused on everybody's involvement. It has been divided into two themes, one dealing with everybody's involvement in the "world of ideas", i.e. how the idea of everybody's involvement is presented in official "CCV 2002" documents; the other dealing with everybody's involvement in the "world of practice", i.e. how the practical change work was carried out.
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HRM and QM in practice - Part I: A new mission In December 1996, a new County Council Director (CCD) was installed at the CCV. The old administrative management had been criticized internally, as well as in the media; it was said that the management consisted of a group of old boys with a masculine view of management. Expectations regarding the new director were thus great among politicians, administrators and labor unions, and everybody felt that she was a good choice. What exactly these expectations consisted of is difficult to say. Some looked forward to a more "modern" management, while others thought it would be exciting to have a new director.
The new director was immediately given an extensive investigation assignment. Among other things, she was asked to present a comprehensive view of, and course of action for, the organization whose point of departure would lie in an analysis of the environment. She was also expected to suggest how the entire CCV would become a learning organization, "where quality development from a customer perspective is a natural way of organizing" (internal document). Another task was to propose how the central County Council offices could be modernized. The group responsible for the development of a learning organization was called DCCV (Development of the County Council of Värmland), and a group consisting of senior administrators had the rest of the issues on their plate. Quite soon, however, there was a spanner in the works regarding the collaboration between the new director and the old administrators. One of the DCCV members left his position and wrote a letter to the county council director.
I can't express any solidarity with the way the group operates. I feel that the work is being done superficially and in great haste. My experience is that there is not enough time for basic discussions from a common viewpoint, which is why we missed out on laying one of the
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cornerstones of a learning organization. (Letter from an administrator to the County Council Director Feb. 10, 1997)
The director noticed early on that the collaboration between her and her closest administrators was not functioning in a satisfactory way.
It only took about two weeks until I started feeling the opposition. That is when they began to sham work. They didn't show up or share any information. I don't think my honeymoon even lasted two weeks. (County Council Director)
The administrators also felt that their expectations regarding the new director were not being met. A conflict developed between the director and the majority of the old administrators.
After a while, the situation in the central office became intolerable. One of the commissioned tasks was to reorganize the central office, and, with the conflict in mind, the director decided to advertise the positions of the senior administrators. Most of them were replaced. One of the newcomers was the financial director, who, together with the CCD, became one of the driving forces behind CCV 2002, that was initiated in May 1998. At a meeting in June of the same year, the Gräsmark group, as it was known, was formed and commissioned with presenting an overall organizational strategy as the guide for the change program. This group consisted of senior administrators, senior doctors and some representatives of the nursing staff. At their meeting in June, they drafted an outline of a business plan, which was then revised at a meeting in August. This comprehensive business plan is the most important document regarding how the change program was meant to be carried out and provides a good understanding of the idea of everybody's involvement within the CCV.
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The idea of everybody's involvement at CCV CCV 2002 was a project that was expected to permeate every level of the CCV. The basic idea was expressed in the comprehensive organizational strategy for the years 1999-2002. The all-embracing vision was that Värmland would become "an attractive, dynamic, and health promoting province" (CCV, 1998, p. 56). Based on the vision, three goals were formulated: satisfied citizens, satisfied coworkers and a balanced economy. The symbol for the project was a triangle with the vision in the middle and one of the three goals at each corner.
There is a good chance that these goals can reinforce each other. If the citizens of Värmland are satisfied with the CCV's output, this will affect everybody's feeling of inclusion and involvement, which will lead to increased employee motivation to further improve the organization for the good of the patients and all the citizens. This will result in improved efficiency and resource utilization, which in turn will contribute to the economic balance. We will enter a virtuous circle. (CCV, 1998, pp. 57-58)
The comprehensive organizational strategy was designed with the help of the LOTS model, a tool for organizational development and a pattern for writing and structuring business plans. The model can be seen as a organizational development process model. Somewhat simplified, it can be said that the present and history of the organization serve as the basis upon which goals and aims are formulated. Success factors are listed, followed by what kind of formal structure, type of personnel, and what activities are required in order to reach these goals. The most important success factor at the CCV was involvement of the employees. Involvement, as stated in the business plan, was not only expected to motivate the employees, but also to become a strategic success component in building an organization based on a customer perspective.
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The distinguishing mark of organizations that have been capable of improvement and of increasing their competitive power is that their employees have been involved in the process and have understood and accepted the motives behind the changes. The unsuccessful ones have often failed because the process has been carried out without involving the coworkers, causing them to feel steamrollered and unmotivated. A high degree of involvement is automatically inducive to a commitment to the task. (CCV, 1998, p. 52)
Increased involvement among the employees is expected to contribute to reaching both goals of satisfied employees and satisfied patients. But exactly what does everybody's involvement mean?
For instance, the fact that the employees feel that they can exert a considerable influence on their own work situation and work environment ?It is also important that they are committed to the new way of working and continuously informed about what is happening, and that they can clearly see the positive consequences of their day-to-day work. (CCV, 1998, p. 52)
The employees must also be given the chance to become involved by means of a high degree of delegation. This requires extensively participating in and feeling accountable for the organization as a whole; not just for the immediate tasks they have been hired to deal with, but also for the organization's future. They must feel it is their right to exert influence coupled with responsibility, even outside their own workgroup.
For this to happen, it will be necessary for the employees to know that their entire capacity is being put to use. Above all, it is about seeing opportunities for the individuals to grow on the basis of their personal abilities and interest in order to become stimulated to take on new and extended tasks. Ultimately, it is a question of creating environments where each and every one
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of us is given a chance to grow, develop, and feel joy and satisfaction over a job well done. (CCV, 1998, p. 53)
One way for the employees to influence the organization outside their own workgroup and to grow as people was through participation in the newly formed process groups. The CCV's main goals, aims, success factors etc were listed in the comprehensive business plan, but in order for these to be realized, the employees in the operative organization had to be committed to the task. Process groups were assigned to deal with various diagnoses and patient categories and to actualize the thoughts expressed in the comprehensive business plan. The LOTS model and its structure were to be the tool that would help formulate the business plans which the process groups were to produce. A customer perspective should always be in focus. All process groups were asked to draw a process map showing a typical patient's move through the organization (CCV, 1998).
HRM and QM in practice - Part II: Discussion on everybody's involvement In the middle of November, the politicians accepted the comprehensive business plan and a few days later the Gräsmark group met for the third time to discuss the start-up of a number of process groups. During the meeting, which we observed, the discussion revolved mostly around everybody's involvement instead of the startup.
The Gräsmark group was divided into subgroups for the first round of discussions on CCV 2002, namely everybody's involvement, which was an honorary term for the new management. Following the group discussions, a measuring instrument was designed to determine just how involved the members of the Gräsmark group felt that they had been in the project. The scale was graded from zero to four, where zero stood for not informed at all, and four stood for views taken into consideration. The majority put themselves on zero or one, a 15
very discouraging result. A number of suggestions were formulated regarding how to increase involvement. ? More flexible use of the methodology. ? Management must heed the incoming views and respect the assigned responsibilities. ? Explanation of the goal conflicts between a balanced economy and satisfied citizens in order to increase credibility.
When work started up after lunch, the discussion about everybody's involvement continued, seemingly having been fueled during the break. Doctors voiced the opinion that few would seek participation in CCV 2002 on their own; they would have to be activated to become involved. One threat to participation was the one-week residential course prescribed by the LOTS model. The argument put forward was that the model should not be allowed to become a goal in itself; the important thing was the result. One doctor also claimed that the impression being given by the project was that it was controlled from the top. The polarization between the driving forces behind the project (the new management) and a major part of the Gräsmark group became evident. The new management argued that the "week" would be very important - it was meant to cause a change in values and boost the feeling of involvement. The new management saw CCV 2002 as a paradigmatic shift, which was to be carried out in a form that perhaps would be unfamiliar to some.
The discussion was interrupted and another group session started, this time focusing on how to design the information campaign for CCV 2002 - i.e. who was to be informed, when and how. Moreover, this time the discussion was more about everybody's involvement and about the week away from normal duties than on the information strategy. During the summing up of the group sessions, the "week" was directly called into question even though the overall
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method was considered ok. The new managers claimed that the "week" was important in order to bring about a fundamental change - not just on paper. "We must alter our own way of thinking" said the financial director. Another person stated that the "week" needed to be discussed, but that CCV 2002, in combination with the LOTS model, had been designed to cause a paradigmatic shift. Subsequently, one of the newly-appointed senior administrators summed up the discussion and stated that two things seemed to be problematic, namely the information, since so few feel involved, and the "week". The purpose of the "week", he stressed "?is to change values and attitudes as this in many respects is what it is all about. This is difficult."
To cool down the somewhat infected atmosphere, one person proposed that an alternative to the week away could be discussed as follows: ? One 24-hour period as a start and then three days at another point in time. ? Total freedom. ? One 24-hour period as a start, repeated at the end of the process and the time in between, total freedom.
Time to reflect on the proposals was granted. When the discussion continued, the new management was still claiming that the "week" had to be retained in order to change attitudes and values. A few doctors questioned whether a week like this would make any difference at all. One senior administrator argued that this was a cultural change. Another doctor leveled criticism at the working methods of CCV 2002.
The polarization between the new management and the rest was now quite clear. All of a sudden some doctors got up and said: "That's enough, we're going home". They gathered
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their belongings and walked toward the exit, followed by some hospital managers. Somebody close to the member of our ranks who was observing the meeting said, "This is the end of the project". Once everybody was seated again and some calm had been restored, it was decided to vote on the various alternatives. Practically everybody voted for total freedom, which meant the new management being steamrollered.
Everybody's involvement had been communicated as an important success factor for CCV 2002 by the new management. The meeting with the Gräsmark group showed that some senior doctors, as well as certain senior administrators, did not feel involved. To map the problems around the concept of everybody's involvement, a number of interviews, summarized in the next section, were carried out among the senior administrators, doctors and nurses.
Empirical reflections on everybody's involvement The new managers often stressed the importance of everybody's involvement, but the concept became problematic for them. What was interpreted as control being exercised by top management caused many to think that there was a discrepancy between management's word and deed. Consequently, the word 'involvement' had a false ring to it. The administrators and staff of the public health system saw only the highest administrative management being involved in CCV 2002. One reason for this was the perceived discrepancy between word and deed. Another was, conceivably, the attitude toward the rest of management being exercised by the CCD and the financial director. The administrators, in particular, had a feeling that the new management was criticizing the CCV's past while praising what was coming. This disappointed many who had participated in accomplishing a rather successful cost reduction exercise at the beginning as well as the middle of the 1990s.
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Very much of the spirit here was; get rid of the past, weed out. This spirit became more evident when the financial director was hired; the spirit of rejecting history and putting an emphasis on the changes?but things were not as bad as they [the new management] had described them. If they had been a little keener to put an emphasis on the positive side of our history, they could have been very sharp on the critique as well. The critique they put forward was too sweeping. If they had been more specific in their critique, they might have established trust and mutual confidence. (Administrator)
The new management, for their part, felt that the resistance to them, above all from the administrators, was founded on an old-fashioned view of management. They claimed that the mentality that was termed "the old boys' club" in the central office at the beginning of the empirical story still existed and resisted new ideas. The new management claimed that "the club" ideologically preferred Värmlandsvägen, which was the old, leading organizational ideology. Its central mission was to save the five hospitals in Värmland, which "the club" saw threatened by the CCV 2002.
The overall policy being set by them [the old administrators] was that all five hospitals in Värmland would be retained. This was stated in the Värmland Way, which was their baby, their creation. (County Council Director)
According to the new management, however, it was not only an ideological conviction but also a struggle for power that lay behind the resistance. The chance for advancement had been reduced for many people under the new management, as a result of the developed conflict. The new management described the County Council of Värmland as an old-fashioned organization unwilling to change.
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After working for 25 years in public organizations, the County Council of Värmland was a completely new experience. I had never experienced such a backward organization. (Financial director)
Even if there were conflicting views on a lot of things within the organization, as well as on how CCV 2002 should be conducted, everybody seemed to agree that the intended involvement did not come about.
Interpretation: The separate worlds of HRM/QM
In this section, we interpret the empirical story from a sensemaking perspective (Weick, 1979; 1995). Our interpretation will be structured in accordance with an analytical separation between semantic and normative sensemaking (see the theory section). We begin with the former.
Semantic interpretation Words and concepts are used to join disparate thoughts in agreement and action. This is a central aspect of management and communication during organizational change (Müllern and Stein, 1999). From the empirical section it is clear that the concept of everybody's involvement attracted the co-workers' and managers' attention and interest. Expectations rose that the new management would listen and accept different views and suggestions. We can see everybody's involvement as an extracted cue that had a positive charge for most. Consequently, everybody's involvement made sense on an individual level - everybody seemed to understand the concept.
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However, the meaning varied between different groups on the collective level, the greatest difference being apparent between the new management and the rest of the employees. The new management was of the opinion that not everyone could participate in everything, e.g. in strategic issues and issues regarding how to plan projects, which was considered management issues. Others thought that they were to share in the change work not only by carrying out the actual tasks in the process groups, but also through involvement in the very formation of the project - through exerting influence on its primary premises and goals.
Looking at the practice today, we can draw the conclusion that discussions regarding everybody's involvement in day-to-day tasks are completely lacking and accordingly that the project did not normalize the practice of involvement. We thus claim that we can identify individual sensemaking on the semantic level but that different groups arrive at different meanings, which is why shared meaning failed to take shape. Nor has any separate group formulated a meaning totally corresponding with the concept as it is presented in the business plan. On the other hand, the new management had raised expectations throughout the organization concerning the implementation of CCV 2002, and what results it would accomplish.
One reason for the lack of shared semantic meaning was the fact that there was no clear sensegiving activity (Gioia and Chittipeddi, 1991; Gioia et al., 1994) concerning the concept of everybody's involvement. Each employee formed his/her own meaning without the influence of management. Not many seemed to have read the business plan or let them selves be guided by it in their sensemaking. It would have been possible to arrange seminars for all employees around the basic concepts of CCV 2002. Instead, the employees formed their own meaning as regards everybody's involvement from their own ordinary understanding of the
21
same. A surgeon can, to a large extent, influence all the steps of the surgical operation and the immediate surroundings, in turn affecting his/her own work situation.
Another plausible reason for the fragmentary meaning was that similar interpretations of the context and organizational history had not been reached. The new management believed that the CCV was an old-fashioned organization with serious problems and that CCV 2002 was the radical solution to those problems. In particular, the administrators throughout the organization were resisting that picture. They thought of the CCV as a sound and stable organization only in need of minor changes. Yet, a more holistic explanation, which account for the resistance from the physicians, is the clash between professional values, such as autonomy, and QM values, such as customer orientation.
The fragmentary sensemaking carried with it different expectations regarding the outcome. The co-workers anticipated a larger degree of involvement than that which actually took place; the new management's actions did not coincide with their expectations. This in turn caused a low participation in CCV 2002 and a common mistrust vis-à-vis the new management. The new management, for their part, felt that they had acted in accordance with what they had promised.
Normative interpretation In the sensemaking process, where the concept of everybody's involvement is given content, the individuals (momentarily) ascribe value judgments to this content. Our texts show that everyone at the CCV considered that everybody's involvement as an idea, in the context of organizational change, was good, while many also felt that it was a necessity. This interpretation is based on the debate concerning the concept as well as the feelings that this
22
debate was an expression of. In the semantic interpretation, we also claim that many individuals extracted the cue, which was an indication of its importance to them. Others were disappointed that they were not allowed to participate to the extent that they had expected. We must also presume that the new management regarded the concept as important to the success of the organizational change, since everybody's involvement was something of a key idea.
Different meanings were formulated around the practiced involvement, on a normative level as well. The new management found it successful but also understood that the rest of the employees considered it insufficient, since to them the rhetoric of the change work did not comply with the reality. We argue that the main reason for this was the fragmentary meaning on the semantic level. Different anticipations circulated as the new management attached other meanings to everybody's involvement than did the employees. What the new management had expected was in conformity with the actual course of events, whereas, among the rest of the employees, the evaluation of the (alleged) realized involvement was negative.
To summarize, we can state that almost all individuals considered everybody's involvement to be an important and positive part of human resource and quality practice. On the other hand, only the new management felt that the practiced involvement was good, the reason being that different semantic interpretations were attached to the concept. What, then, is the fundamental difference between the new management and the rest of the employees?
Different worlds In the introduction, we argued that the concept of everybody's involvement had not been clearly defined in earlier research. We also explained that the logic of the world of ideas and
23
the world of practice sometimes differs (Brunsson, 1993), which is why the empirical section was structured according to these dimensions. In this section, the argument is that the new management and the other employees of the CCV lived in different worlds, namely that they operated within heterogeneous cognitive frames, and that this was the main cause of the fragmentary sensemaking and the lack of contextualization.
The CCV's new management was externally recruited, and the new managers brought a number of ideas for modernizing the work. For example, they presented CCV 2002 as a paradigmatic shift. Even if they were well-experienced in managing the public sector, they had no specific experience in managing or working in the health and medical sectors. Consequently, they attempted to translate ideas that they knew functioned well in other sectors to the new organization. They lived in the "world of ideas".
The rest of the employees had no real knowledge of HRM and QM, either as concepts or in practice. The CCV had become known as a County Council opposing the New Public Management (Hood, 1995) ideas of change, wherein HRM and QM is a central issue (Power, 1997), that other County Councils had begun to use at the end of the 1980s (Skålén, 2002). Most of the employees based the sensemaking of CCV 2002 on the present practice - they lived in the "world of practice".
The two worlds were not united; contextualization did not come about. People continued to live in different worlds, meaning that they used different "languages" and different cognitive frames, attached different meanings to the concept of everybody's involvement and formed different attitudes toward HRM and QM ideas. The sensemaking became fragmentary as a result of the heterogeneous cognitive frames. However, this could have been avoided if the
24
two worlds had been united, i.e. if the ideas had been modified to fit the existing practice. The present paper stresses the importance of the process that we call contextualization. Ideas must be adapted to fit the practice in order to create shared meaning.
Implications
As stated in the introduction, the need for contextualization and translation has previously been noted in research into organizational change in general (Czarniawska and Joerges, 1996; Rövik, 2000), but the concept has been weakly elaborated in a HRM and QM context. We believe that the sensemaking framework applied in this paper has added sharpness and precision to the concept of contextualization, as well as an understanding of how contextualization is realized. Concerning the latter issue, we would like to stress the importance of uniform enactments of reality, similar interpretations of the context and the organizational history, and sensegiving activities in order to reach shared meaning. Future research must focus on strategic change programs based on HRM and QM ideas where contextualization is realized in order to strengthen our conclusions. In addition to such research it would also be of value to understand the coupling between cognition and action in the context of strategic change based on HRM and QM. Our paper and the concept of contextualization deals with the coupling between ideas and shared meaning, but a common understanding of HRM and QM does not imply action in accordance with them, even though it is a precondition for such action.
The present paper is primarily devoted to organizational change, improvement of HRM and QM issues in particular. But we also regard our analytical distinction between normative and semantic sensemaking to be a contribution to studies of sensemaking. Our distinction corresponds with the distinction between "cold" and "hot" cognition in general psychological
25
cognition studies (Klimoski and Donahue, 2001). According to the former view, person perception is rational, information-driven processes while the latter emphasizes normative, motivational and affective processes. Weick (1979; 1995) emphasizes cold cognition. We do believe, however, that it is important to include hot cognition in the analysis as well, which our distinction between semantic and normative sensemaking indicates. For future research, we recommend a more elaborated and explicit integration of theories on hot cognition with organizational sensemaking compared with the one provided here.
Our paper also has implications for management practice in organizations. Management must understand the need for contextualization. Managers not only have to acknowledge that strategic change in general, HRM and QM programs in particular, is time consuming, but also that a lot of time has to be spent on preparing for a change before initiating it. Management should concentrate more on paving the way for sensemaking rather than on marketing the impending changes internally. Shared meaning, on the semantic level, has to be realized before the actual change work starts. Management should also identify competent translators, not necessarily themselves, if HRM and QM change processes is to be realized. Translators are people who can bridge the gap between ideas and practice and who thus need to understand the ideas as well as be familiar with the world of practice. Such people are scarce. Lastly, in order for management to handle a sensegiving role, a coordinated view has to be created of just how idea and practice are to interact.
Notes
1
We are thus interested in both the process and effect of sensemaking, which can be seen as a partial departure from Weick's (1979; 1995) focus on process/organizing. There are, however, structural tendencies in Weick's theory as well; for example the concept of the cognitive frame discussed above. 2 We do not use, thus, the concept of fragmentary meaning in the same way as Ericson (2001). 3 According to some research into organizational culture, fragmentary meaning is a very natural thing (Alvesson, 2002, Martin, 2002; Parker, 2000), because complex organizations call for a high degree of differentiation of meaning contingent upon the various practices people are engaged in. A similar argument have been put forward by some of the proponents of QM, which have suggested its ambiguity is a great virtue (Wilkinson et al., 1998; Wilkinson and Willmott, 1995
. We also believe that complex organizations, especially in healthcare, are
26
fragmented and in the ambiguity of QM and that both this issues can be good for the organization. However, in this paper, we focus on the idea of everybody's involvement in quality improvement work. Everybody's involvement concerns how the process of quality work should be organized throughout the entire organization. Thus, it is important to achieve, as we have argued, shared meaning, i.e. '?identical, or at least similar, meaning?' (we thus allow for some differentiation). On the other hand, we think it is natural and good that the effect (as opposed to the process) of quality improvement work in different departments (as opposed to the whole organization) differs significantly, since the department's objectives and tasks vary substantially. 4 Sweden's healthcare is geographically divided into 21 County Councils. Each County Council has a political assembly. The politicians of the CCV decided to embark upon quality improvement work but were not engaged in the actual quality work itself. Thus, the political level has not been studied in depth. 5 A complete account of the rules of the MCD analysis can be found in Silverman (1993).
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doc_301175051.docx
The term quality management has a specific meaning within many business sectors. This specific definition, which does not aim to assure 'good quality' by the more general definition, but rather to ensure that an organization or product is consistent, can be considered to have four main components: quality planning, quality control, quality assurance and quality improvement.
Research Reports on Contextualization of Human Resource and Quality Management
A sense making perspective on everybody's involvement
Abstract
The principal idea of this paper is that human resource management (HRM) and quality management (QM) ideas require contextualization when used to change organizations. Here, contextualization stands for the process that leads to a shared meaning, i.e. that the majority of the co-workers in an organization understand and define a concept or change in terms that are shared and accepted. In the present paper, we study a strategic change project, based on HRM and QM ideas, conducted at the County Council of Värmland (CCV), the public healthcare authority in the County of Värmland in Sweden, where the focus was on everybody's involvement. Our interpretation of the project shows that a shared meaning of the concept of everybody's involvement was not reached in this particular case; i.e. contextualization did not occur. One important result of the study is that contextualization is a prerequisite for realizing HRM and QM thoughts. The paper also stresses how important it is that general and "non-contextualized" HRM and QM ideas is adapted to local practices when used to direct organizational change.
Keywords: Contextualization, Sensemaking, Human Resource Management, Quality Management, Everybody's involvement, Health care.
Introduction
Human Resource Management - HRM - and Quality Management - QM - have much in common. As an example, both disciplines address the importance of the empowerment of employees through everybody's involvement in strategic change processes in order to gain employee and customer satisfaction and increased effectiveness (Beer and Spector, 1985; Beer et al., 1985; Crosby, 1979; Deming, 1986; Juran, 1988). However, the effects of HRM and QM practices have been much debated. In the HRM context, research has found that empowerment programs do not deliver what they promise (Argyris, 1998; Edwards and Collinson, 2002; Hales, 2000). Explanations to the lack of positive effects have emphasized that junior managers, compared to senior management, have a more pragmatic and contextdependent interpretation of empowerment (Hales, 2000) and "?that managers do not expect as much from the term as some of the hype may have suggested" (Edwards and Collinson, 2002:294). In the QM context, research has also found that practices of QM, such as process and customer orientation, fail to materialize (Skålén, 2002; Skålén, 2004; Yong and Wilkinson, 1999). One reason often given is weak managerial commitment (Hales, 1991; Yong and Wilkinson, 1999), another is the internal power structure (Skålén, 2004).
We embrace the reasons given in previous research to the failure of HRM and QM practices, but in the present paper we like to make two further arguments. Firstly, the prevalent theories of organizational development in the HRM and QM context are rooted in the prescriptive and positivistic tradition (Beer and Spector, 1985; Beer et al., 1985; Crosby, 1979; Deming, 1986; Juran, 1988). In spite of their ineffectiveness no alternative to these models have been presented. The ambition of the present paper is to suggest an alternative view. Secondly, we like to base our alternative on the assumption that the ideas compromising HRM and QM can be described as non-contextual and general in nature; they are designed to suit any type of
1
organization (Neergaard, 2002; Rövik, 2000; Townley, 2002; Wilkinsson et al., 1998). In support of our claim Edwards and Collinson (2002:286) have shown that the middle managers they interviewed expressed "?considerable ambiguity, even confusion, regarding the meaning of empowerment?".
With our standpoint in theories on organizational sensemaking (Weick, 1979; 1995), we argue that it is sometimes difficult for employees to understand and make sense of the somewhat general ideas that HRM and QM stand for. The organizational practice rests on institutionalized structures and processes (Bourdieu, 1977). This can mean that ideas which are new to the organization can be difficult to implement since the logic of the "world of ideas" and the "world of practice" sometimes differs (Brunsson, 1993). Thus, it can be difficult to apply HRM and QM ideas directly to an organizational practice, which is why a translation process is needed (Latour, 1987) - an adaptation to local conditions - in order to make the ideas understandable in the specific environment. This translation process, from idea to practice, we call contextualization. The need for contextualization and translation has been noted before in research into organizational change in general (Czarniawska and Joerges, 1996; Rövik, 2000), but the concept has been weakly elaborated in a HRM and QM context.
In the present paper, we will study the contextualization of everybody's involvement at the County Council of Värmland (CCV), which is the public healthcare authority in the County of Värmland (Sweden), where an extensive organizational development project, called CCV 2002, was initiated in 1998. The importance of everybody's involvement in change processes have been argued for both in the HRM context, especially within the empowerment debate (Edwards and Collinson, 2002), as well as in the QM context (Edvardsson, 1996a, b). From HRM quarters it has also been argued that Total Quality Management is likely to
2
institutionalize the employee participation and involvement that quality circles failed to do in the 1980s (Hill, 1991; 1995). "TQM has the potential to align reality with rhetoric by means of participation" (Hill, 1991:561). It is clear that the CCV 2002 was inspired both by HRM and QM ideas, since the goals were satisfied citizens, satisfied coworkers and a balanced economy. Also, explicit reference was made to both disciplines by informants to the research presented in this paper. We have chosen to focus on everybody's involvement at the CCV from a sensemaking perspective. What is meant by everybody's involvement has not been well defined in previous research. The concept has neither an explicit nor a commonly accepted content. We have chosen to use the CCV's own definition in the documentation of their organizational development.
The main objective of the paper is to add precision and sharpness to the concept of contextualization and to clarify how contextualization is realized, or not realized. Since, at least, quality improvement work is said to be an excellent context for the study of sensemaking (Weick, 2000), a secondary objective is to introduce an analytical distinction between semantic and normative sensemaking in order to advance the knowledge of organizational sensemaking in theory and practice.
The paper is structured as follows. We begin with a review of Weick's theory on sensemaking (Weick, 1979; 1995), i.e. the theory we used to study the contextualization of the concept of everybody's involvement at the CCV. Next comes the interpretative methodology of the paper and a review of the methods used to collect and structure the empirical material. An empirical section divided into two themes follows - one regarding the very idea of everybody's involvement at the CCV and one on the practical strategic change work. After the empirical part, there follows an interpretative section wherein the empirical material is
3
seen and understood from a sensemaking perspective. Finally, we discuss what implications the paper has for research and practice of HRM and QM.
Contextualization as sensemaking
In this section, we introduce the theoretical perspective that we use to explain and understand (Ricoeur, 1993), and to define contextualization and a lack of the same. Our perspective is based on Weick's theory of sensemaking (Weick, 1979; 1995), which is well suited to the interpretation and analysis of how local common conceptions develop, or do not develop, in an organization (Quist, 2003; Skålén, 2002). Sensemaking regarding everybody's involvement, in the present paper, constitutes a "measurement" of the degree of contextualization at the CCV.
Individual sensemaking There is a difference between experiencing something new and experiencing something a second time. For instance, there is a major difference in doing the weekly shopping in a grocery store for the very first time compared to going to one's usual store. In stores we are familiar with, our shopping is done more or less automatically, while shopping in unfamiliar surroundings requires an effort in order to come away with the necessary items in one's bags. Weick (1995) explains this with the help of the concepts of cognitive frame and cue, and the connection between them. An individual has a cognitive frame within which he or she has put together a list of actions relating to grocery shopping. Even as one is leaving home, this action list is set in motion and helps the shopper understand the upcoming events, recommending suitable alternatives as regards how to handle them. With the help of this list one can, for example, on one's way through the store, become aware that there is no bread in the shopping cart (a cue). One knows that bread is always needed and that by now it should be in the cart,
4
since the bread section is located just inside the entrance. Realizing this, the individual can quickly decide what mode of action to choose in order to get the bread with the least possible effort. Without such a detailed list of action schemes, for example when shopping in an unfamiliar store, one cannot, from the items in the shopping cart, make the same kind of sense. When a cue is set in a cognitive frame, it can make sense all together - which can be seen as a concentrate of the concept of sensemaking on an individual level.
Sensemaking, however, is not comparable to the interpretation of extracted cues. Sensemaking is about "reading" the "text" as well as "writing" it. Weick (1995) argues, hence, that individuals actively create the environment they extract cues from; they "?produce part of the environment they face" (p. 30). He introduces enacted environment to describe the result of the process of creating an environment. Environments are enacted when something surprising or unusual happens, for example when a reform program is introduced in an organization, and provides the starting point for sensemaking. The enactment of reality is informed by the cognitive frames, since the latter have an impact on the actions taken, which in turn creates the response perceived. It is thus probable that the same shopper creates different meanings from similar events happening on two different days. When forgetting the bread, for example, the shopper might buy bread on one shopping occasion but not on the next. Instead, he/she may decide to buy yeast and wheat flour in order to bake when back at home.
As is evident from the shopping example, sensemaking works retrospectively; it is driven by history. Previous experience and actions are the building blocks of the cognitive frames (Weick, 1979). By comparing flows of events faced with past experience, people make sense of that flow. If one grocery shopper has experience of grocery shopping in Shanghai and another of shopping in London, their shopping behavior when moving to New York will be different. But it must also be noted that the actual context of the sensemaking event has a great impact on what cognitive frames are applied in order to extract cues from the enacted environment and how, and with which result, the cues are interpreted (Weick, 1995). 5
Shopping in Chinatown in New York might not be that different than shopping in Shanghai after all.
Collective organizational sensemaking How can individuals' sensemaking be of such great interest to those who want to study organizations? Is collective sensemaking possible? Weick (1995) takes his point of departure in Wiley (1988) when reasoning about sensemaking above the subjective individual level. What is called shared meaning in the present paper (cf. generic subjectivity, Weick, 1995) refers to the possibility that most individuals in an organization formulate identical, or at least similar, meanings regarding an event or a new concept. If shared meaning is formulated within the CCV on the concept of everybody's involvement, we interpret this as contextualization - the idea and the world of practice have entered into symbiosis. 1 Its counterpart we call fragmentary meaning2, which means that the individual's sensemaking in an organization with regard to a change or a concept, in our case everybody's involvement, differs. Fragmentary meaning is ranked as failed contextualization. We claim that, with contextualization, a common definition of reality will be reached, which is a prerequisite for change of practice. On the other hand, failed contextualization will cause antagonism between actors who have different definitions of reality and who will additionally prevent a change of practice. Consequently, shared meaning/contextualization should be the purpose of the change program at the CCV, as in other organizations.3
Somewhat simply stated, shared meaning requires the individuals to jointly extract and closely examine the cue in order to come to an agreement about its meaning. They need to formulate similar answers to the question: What is actually happening? It requires the individual's cognitive frames about this cue to be relatively homogeneous, which is dependent on the similarity of the enacted environments and a similar interpretation of the 6
context and organizational history being reached. The reason for fragmentary meaning can, for instance, be the opposite, i.e. that the individuals do not extract the cue at all, that they have heterogeneous cognitive frames, or that the enacted environments differ substantially. Within a large organization such as the CCV, it is possible to distinguish several smaller groups. In our interpretation, we will demonstrate how the differences between various smaller groups build fragmentary meanings, as seen in the perspective of the whole group.
An interpretation of the collective sensemaking in an organization is built on the sensemaking on the individual level. Two interesting questions emerge during the individual phase of the interpretation: Do the individuals extract the cue? What meaning is created from the cognitive frame(s) in use? The interpretation then turns to the collective level, and the main question is whether the meaning is shared or fragmentary. To what extent is the sensemaking shared? In order to answer that question, i.e. to understand if contextualization is achieved or not, we make a distinction between semantic and normative sensemaking. Semantic sensemaking refers to how individuals define or understand a word or concept. If the employees of the CCV express similar opinions about everybody's involvement , we interpret that as a sign of shared meaning, whereas if opinions differ, then sensemaking is characterized as fragmentary. With normative sensemaking, we mean whether a certain initiative to change the organization is considered desirable or undesirable, as well as whether the actors perceive the practice that such an initiative generates in positive or negative terms. In the present paper, this part of the interpretation deals with the question of whether everybody's involvement by the employees of the CCV was considered recommendable or not, and what possible positive or negative consequences this entailed in the world of practice. If the employees believed that everybody's involvement was to be recommended, and if they felt that it turned out well in practice, this is a sign of shared meaning. If, however, everybody's involvement as an idea
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and practice was perceived as something undesirable, this will be interpreted as a sign of the contrary, namely fragmentary meaning.
Sensegiving Another central concept in the theory on sensemaking is sensegiving. Smircich and Morgan (1982) write about the "Management of meaning", presupposing that management is a social process defined through the interaction between leader and follower. Their description of the phenomenon of management includes the task of defining reality in a way that seems sensible to those who are being led, who themselves have relinquished their right to interpret and define organizational reality. According to the authors, this process creates common reference points as a basis for organizational action. Management cannot expect shared meaning to emerge on its own, but should attempt to influence and facilitate the employees' sensemaking. Gioia and Chittipeddi (1991) and Gioia et al., (1994) have observed in their studies the relationship between the individual's own sensemaking and how that of others influences them. They coin the concept "sensegiving" to explain the processes that arise when someone attempts to influence somebody else's sensemaking. The dialectic relationship between making sense by oneself, as opposed to influencing other people's sensemaking, is also an important part of the concept of sensegiving. It is not as simple as first making sense for oneself and then trying to sway others; while an individual is influencing others, his/her own sensemaking is being affected as well.
Methodology and method
In the field of organization theory, a distinction is often made between functionalistic and interpretative methodology (Burrell and Morgan, 1979). Research into HRM and QM often relates to the former category. However, the present paper rests on an interpretative
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methodology (Alvesson and Sköldberg, 2000) and a social constructionist world-view (Berger and Luckmann, 1967). In our paper, the empirical level (Alvesson and Sköldberg, 2000) emerges as a story in several parts about the change program at CCV in general an everybody's involvement in particular. The criterion for truth in interpretative methodology is built on the argumentation in the stories presented (Czarniawska, 1999). The task of the researcher, then, is to present a dialectic communication between the presented story and the interpretative framework (theory) from which the interpretation finds its argumentation for a credible, i.e. rich in point (Alvesson and Sköldberg, 2000), interpretation.
In order to find material for the empirical story, we studied the change program labeled CCV 2002. The empirical study lasted approximately two and a half years (from the fall of 1998 until the beginning of 2001). We used a number of "techniques" - interviews, participant observation, and document studies. Altogether, 37 unstructured interviews (Silverman, 1993) were carried out which lasted between 40 minutes and two hours. The interviews can be described as conversations about the change program with CCV employees, mostly administrators, doctors, and nurses. 4 The respondents were selected from those who participated actively in the CCV 2002. An even distribution of gender and co-workers from the various personnel categories was aimed at. In addition to interviews, we carried out two months of participant observation of meetings regarding CCV 2002. The occasions we observed were selected because they were important as regards the progress and development of the change program. In addition to this, we studied everything written in the daily press from 1990 to 2000 about the CCV (approximately 25 folders of material), as well as internal documentation of organizational development which had taken place during the same time period.
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The empirical material was structured with the help of Silverman's (1993) Membership Categorization Analysis (MCA) technique. Accordingly, we arranged the material in three categories, i.e. pertaining to doctors, nurses and administrators. The next step in the structuring process was to arrange these into main categories, a process called the Membership Categorization Device (MCD). Silverman (1993) lists a number of rules governing how MCD is to be constructed. The purpose of the rules is to help group the individuals so that those who are bonded by common views are placed in the same Membership Category.5 The MCD analysis resulted in the formation of two main categories the new management and the rest of the employees - since these showed different attitudes towards everybody's involvement during the initiation of the CCV 2002. The new management was the driving force; the rest of the employees were passive and, in certain cases, vaguely unsympathetic. Considering that the primary ambition of the present paper is to study the emergence/absence of contextualization/shared sensemaking, we regard MCA to be the most sufficient method to use when structuring the material, especially - as was clearly explained in the previous section - since our interpretation of the sensemaking will concentrate on whether or not a shared meaning was created within the organization. If the various action groups that emerged during the process did not form similar meanings, contextualization failed.
Empirical story
This section presents the empirical story of the change program at the CCV, focused on everybody's involvement. It has been divided into two themes, one dealing with everybody's involvement in the "world of ideas", i.e. how the idea of everybody's involvement is presented in official "CCV 2002" documents; the other dealing with everybody's involvement in the "world of practice", i.e. how the practical change work was carried out.
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HRM and QM in practice - Part I: A new mission In December 1996, a new County Council Director (CCD) was installed at the CCV. The old administrative management had been criticized internally, as well as in the media; it was said that the management consisted of a group of old boys with a masculine view of management. Expectations regarding the new director were thus great among politicians, administrators and labor unions, and everybody felt that she was a good choice. What exactly these expectations consisted of is difficult to say. Some looked forward to a more "modern" management, while others thought it would be exciting to have a new director.
The new director was immediately given an extensive investigation assignment. Among other things, she was asked to present a comprehensive view of, and course of action for, the organization whose point of departure would lie in an analysis of the environment. She was also expected to suggest how the entire CCV would become a learning organization, "where quality development from a customer perspective is a natural way of organizing" (internal document). Another task was to propose how the central County Council offices could be modernized. The group responsible for the development of a learning organization was called DCCV (Development of the County Council of Värmland), and a group consisting of senior administrators had the rest of the issues on their plate. Quite soon, however, there was a spanner in the works regarding the collaboration between the new director and the old administrators. One of the DCCV members left his position and wrote a letter to the county council director.
I can't express any solidarity with the way the group operates. I feel that the work is being done superficially and in great haste. My experience is that there is not enough time for basic discussions from a common viewpoint, which is why we missed out on laying one of the
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cornerstones of a learning organization. (Letter from an administrator to the County Council Director Feb. 10, 1997)
The director noticed early on that the collaboration between her and her closest administrators was not functioning in a satisfactory way.
It only took about two weeks until I started feeling the opposition. That is when they began to sham work. They didn't show up or share any information. I don't think my honeymoon even lasted two weeks. (County Council Director)
The administrators also felt that their expectations regarding the new director were not being met. A conflict developed between the director and the majority of the old administrators.
After a while, the situation in the central office became intolerable. One of the commissioned tasks was to reorganize the central office, and, with the conflict in mind, the director decided to advertise the positions of the senior administrators. Most of them were replaced. One of the newcomers was the financial director, who, together with the CCD, became one of the driving forces behind CCV 2002, that was initiated in May 1998. At a meeting in June of the same year, the Gräsmark group, as it was known, was formed and commissioned with presenting an overall organizational strategy as the guide for the change program. This group consisted of senior administrators, senior doctors and some representatives of the nursing staff. At their meeting in June, they drafted an outline of a business plan, which was then revised at a meeting in August. This comprehensive business plan is the most important document regarding how the change program was meant to be carried out and provides a good understanding of the idea of everybody's involvement within the CCV.
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The idea of everybody's involvement at CCV CCV 2002 was a project that was expected to permeate every level of the CCV. The basic idea was expressed in the comprehensive organizational strategy for the years 1999-2002. The all-embracing vision was that Värmland would become "an attractive, dynamic, and health promoting province" (CCV, 1998, p. 56). Based on the vision, three goals were formulated: satisfied citizens, satisfied coworkers and a balanced economy. The symbol for the project was a triangle with the vision in the middle and one of the three goals at each corner.
There is a good chance that these goals can reinforce each other. If the citizens of Värmland are satisfied with the CCV's output, this will affect everybody's feeling of inclusion and involvement, which will lead to increased employee motivation to further improve the organization for the good of the patients and all the citizens. This will result in improved efficiency and resource utilization, which in turn will contribute to the economic balance. We will enter a virtuous circle. (CCV, 1998, pp. 57-58)
The comprehensive organizational strategy was designed with the help of the LOTS model, a tool for organizational development and a pattern for writing and structuring business plans. The model can be seen as a organizational development process model. Somewhat simplified, it can be said that the present and history of the organization serve as the basis upon which goals and aims are formulated. Success factors are listed, followed by what kind of formal structure, type of personnel, and what activities are required in order to reach these goals. The most important success factor at the CCV was involvement of the employees. Involvement, as stated in the business plan, was not only expected to motivate the employees, but also to become a strategic success component in building an organization based on a customer perspective.
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The distinguishing mark of organizations that have been capable of improvement and of increasing their competitive power is that their employees have been involved in the process and have understood and accepted the motives behind the changes. The unsuccessful ones have often failed because the process has been carried out without involving the coworkers, causing them to feel steamrollered and unmotivated. A high degree of involvement is automatically inducive to a commitment to the task. (CCV, 1998, p. 52)
Increased involvement among the employees is expected to contribute to reaching both goals of satisfied employees and satisfied patients. But exactly what does everybody's involvement mean?
For instance, the fact that the employees feel that they can exert a considerable influence on their own work situation and work environment ?It is also important that they are committed to the new way of working and continuously informed about what is happening, and that they can clearly see the positive consequences of their day-to-day work. (CCV, 1998, p. 52)
The employees must also be given the chance to become involved by means of a high degree of delegation. This requires extensively participating in and feeling accountable for the organization as a whole; not just for the immediate tasks they have been hired to deal with, but also for the organization's future. They must feel it is their right to exert influence coupled with responsibility, even outside their own workgroup.
For this to happen, it will be necessary for the employees to know that their entire capacity is being put to use. Above all, it is about seeing opportunities for the individuals to grow on the basis of their personal abilities and interest in order to become stimulated to take on new and extended tasks. Ultimately, it is a question of creating environments where each and every one
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of us is given a chance to grow, develop, and feel joy and satisfaction over a job well done. (CCV, 1998, p. 53)
One way for the employees to influence the organization outside their own workgroup and to grow as people was through participation in the newly formed process groups. The CCV's main goals, aims, success factors etc were listed in the comprehensive business plan, but in order for these to be realized, the employees in the operative organization had to be committed to the task. Process groups were assigned to deal with various diagnoses and patient categories and to actualize the thoughts expressed in the comprehensive business plan. The LOTS model and its structure were to be the tool that would help formulate the business plans which the process groups were to produce. A customer perspective should always be in focus. All process groups were asked to draw a process map showing a typical patient's move through the organization (CCV, 1998).
HRM and QM in practice - Part II: Discussion on everybody's involvement In the middle of November, the politicians accepted the comprehensive business plan and a few days later the Gräsmark group met for the third time to discuss the start-up of a number of process groups. During the meeting, which we observed, the discussion revolved mostly around everybody's involvement instead of the startup.
The Gräsmark group was divided into subgroups for the first round of discussions on CCV 2002, namely everybody's involvement, which was an honorary term for the new management. Following the group discussions, a measuring instrument was designed to determine just how involved the members of the Gräsmark group felt that they had been in the project. The scale was graded from zero to four, where zero stood for not informed at all, and four stood for views taken into consideration. The majority put themselves on zero or one, a 15
very discouraging result. A number of suggestions were formulated regarding how to increase involvement. ? More flexible use of the methodology. ? Management must heed the incoming views and respect the assigned responsibilities. ? Explanation of the goal conflicts between a balanced economy and satisfied citizens in order to increase credibility.
When work started up after lunch, the discussion about everybody's involvement continued, seemingly having been fueled during the break. Doctors voiced the opinion that few would seek participation in CCV 2002 on their own; they would have to be activated to become involved. One threat to participation was the one-week residential course prescribed by the LOTS model. The argument put forward was that the model should not be allowed to become a goal in itself; the important thing was the result. One doctor also claimed that the impression being given by the project was that it was controlled from the top. The polarization between the driving forces behind the project (the new management) and a major part of the Gräsmark group became evident. The new management argued that the "week" would be very important - it was meant to cause a change in values and boost the feeling of involvement. The new management saw CCV 2002 as a paradigmatic shift, which was to be carried out in a form that perhaps would be unfamiliar to some.
The discussion was interrupted and another group session started, this time focusing on how to design the information campaign for CCV 2002 - i.e. who was to be informed, when and how. Moreover, this time the discussion was more about everybody's involvement and about the week away from normal duties than on the information strategy. During the summing up of the group sessions, the "week" was directly called into question even though the overall
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method was considered ok. The new managers claimed that the "week" was important in order to bring about a fundamental change - not just on paper. "We must alter our own way of thinking" said the financial director. Another person stated that the "week" needed to be discussed, but that CCV 2002, in combination with the LOTS model, had been designed to cause a paradigmatic shift. Subsequently, one of the newly-appointed senior administrators summed up the discussion and stated that two things seemed to be problematic, namely the information, since so few feel involved, and the "week". The purpose of the "week", he stressed "?is to change values and attitudes as this in many respects is what it is all about. This is difficult."
To cool down the somewhat infected atmosphere, one person proposed that an alternative to the week away could be discussed as follows: ? One 24-hour period as a start and then three days at another point in time. ? Total freedom. ? One 24-hour period as a start, repeated at the end of the process and the time in between, total freedom.
Time to reflect on the proposals was granted. When the discussion continued, the new management was still claiming that the "week" had to be retained in order to change attitudes and values. A few doctors questioned whether a week like this would make any difference at all. One senior administrator argued that this was a cultural change. Another doctor leveled criticism at the working methods of CCV 2002.
The polarization between the new management and the rest was now quite clear. All of a sudden some doctors got up and said: "That's enough, we're going home". They gathered
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their belongings and walked toward the exit, followed by some hospital managers. Somebody close to the member of our ranks who was observing the meeting said, "This is the end of the project". Once everybody was seated again and some calm had been restored, it was decided to vote on the various alternatives. Practically everybody voted for total freedom, which meant the new management being steamrollered.
Everybody's involvement had been communicated as an important success factor for CCV 2002 by the new management. The meeting with the Gräsmark group showed that some senior doctors, as well as certain senior administrators, did not feel involved. To map the problems around the concept of everybody's involvement, a number of interviews, summarized in the next section, were carried out among the senior administrators, doctors and nurses.
Empirical reflections on everybody's involvement The new managers often stressed the importance of everybody's involvement, but the concept became problematic for them. What was interpreted as control being exercised by top management caused many to think that there was a discrepancy between management's word and deed. Consequently, the word 'involvement' had a false ring to it. The administrators and staff of the public health system saw only the highest administrative management being involved in CCV 2002. One reason for this was the perceived discrepancy between word and deed. Another was, conceivably, the attitude toward the rest of management being exercised by the CCD and the financial director. The administrators, in particular, had a feeling that the new management was criticizing the CCV's past while praising what was coming. This disappointed many who had participated in accomplishing a rather successful cost reduction exercise at the beginning as well as the middle of the 1990s.
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Very much of the spirit here was; get rid of the past, weed out. This spirit became more evident when the financial director was hired; the spirit of rejecting history and putting an emphasis on the changes?but things were not as bad as they [the new management] had described them. If they had been a little keener to put an emphasis on the positive side of our history, they could have been very sharp on the critique as well. The critique they put forward was too sweeping. If they had been more specific in their critique, they might have established trust and mutual confidence. (Administrator)
The new management, for their part, felt that the resistance to them, above all from the administrators, was founded on an old-fashioned view of management. They claimed that the mentality that was termed "the old boys' club" in the central office at the beginning of the empirical story still existed and resisted new ideas. The new management claimed that "the club" ideologically preferred Värmlandsvägen, which was the old, leading organizational ideology. Its central mission was to save the five hospitals in Värmland, which "the club" saw threatened by the CCV 2002.
The overall policy being set by them [the old administrators] was that all five hospitals in Värmland would be retained. This was stated in the Värmland Way, which was their baby, their creation. (County Council Director)
According to the new management, however, it was not only an ideological conviction but also a struggle for power that lay behind the resistance. The chance for advancement had been reduced for many people under the new management, as a result of the developed conflict. The new management described the County Council of Värmland as an old-fashioned organization unwilling to change.
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After working for 25 years in public organizations, the County Council of Värmland was a completely new experience. I had never experienced such a backward organization. (Financial director)
Even if there were conflicting views on a lot of things within the organization, as well as on how CCV 2002 should be conducted, everybody seemed to agree that the intended involvement did not come about.
Interpretation: The separate worlds of HRM/QM
In this section, we interpret the empirical story from a sensemaking perspective (Weick, 1979; 1995). Our interpretation will be structured in accordance with an analytical separation between semantic and normative sensemaking (see the theory section). We begin with the former.
Semantic interpretation Words and concepts are used to join disparate thoughts in agreement and action. This is a central aspect of management and communication during organizational change (Müllern and Stein, 1999). From the empirical section it is clear that the concept of everybody's involvement attracted the co-workers' and managers' attention and interest. Expectations rose that the new management would listen and accept different views and suggestions. We can see everybody's involvement as an extracted cue that had a positive charge for most. Consequently, everybody's involvement made sense on an individual level - everybody seemed to understand the concept.
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However, the meaning varied between different groups on the collective level, the greatest difference being apparent between the new management and the rest of the employees. The new management was of the opinion that not everyone could participate in everything, e.g. in strategic issues and issues regarding how to plan projects, which was considered management issues. Others thought that they were to share in the change work not only by carrying out the actual tasks in the process groups, but also through involvement in the very formation of the project - through exerting influence on its primary premises and goals.
Looking at the practice today, we can draw the conclusion that discussions regarding everybody's involvement in day-to-day tasks are completely lacking and accordingly that the project did not normalize the practice of involvement. We thus claim that we can identify individual sensemaking on the semantic level but that different groups arrive at different meanings, which is why shared meaning failed to take shape. Nor has any separate group formulated a meaning totally corresponding with the concept as it is presented in the business plan. On the other hand, the new management had raised expectations throughout the organization concerning the implementation of CCV 2002, and what results it would accomplish.
One reason for the lack of shared semantic meaning was the fact that there was no clear sensegiving activity (Gioia and Chittipeddi, 1991; Gioia et al., 1994) concerning the concept of everybody's involvement. Each employee formed his/her own meaning without the influence of management. Not many seemed to have read the business plan or let them selves be guided by it in their sensemaking. It would have been possible to arrange seminars for all employees around the basic concepts of CCV 2002. Instead, the employees formed their own meaning as regards everybody's involvement from their own ordinary understanding of the
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same. A surgeon can, to a large extent, influence all the steps of the surgical operation and the immediate surroundings, in turn affecting his/her own work situation.
Another plausible reason for the fragmentary meaning was that similar interpretations of the context and organizational history had not been reached. The new management believed that the CCV was an old-fashioned organization with serious problems and that CCV 2002 was the radical solution to those problems. In particular, the administrators throughout the organization were resisting that picture. They thought of the CCV as a sound and stable organization only in need of minor changes. Yet, a more holistic explanation, which account for the resistance from the physicians, is the clash between professional values, such as autonomy, and QM values, such as customer orientation.
The fragmentary sensemaking carried with it different expectations regarding the outcome. The co-workers anticipated a larger degree of involvement than that which actually took place; the new management's actions did not coincide with their expectations. This in turn caused a low participation in CCV 2002 and a common mistrust vis-à-vis the new management. The new management, for their part, felt that they had acted in accordance with what they had promised.
Normative interpretation In the sensemaking process, where the concept of everybody's involvement is given content, the individuals (momentarily) ascribe value judgments to this content. Our texts show that everyone at the CCV considered that everybody's involvement as an idea, in the context of organizational change, was good, while many also felt that it was a necessity. This interpretation is based on the debate concerning the concept as well as the feelings that this
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debate was an expression of. In the semantic interpretation, we also claim that many individuals extracted the cue, which was an indication of its importance to them. Others were disappointed that they were not allowed to participate to the extent that they had expected. We must also presume that the new management regarded the concept as important to the success of the organizational change, since everybody's involvement was something of a key idea.
Different meanings were formulated around the practiced involvement, on a normative level as well. The new management found it successful but also understood that the rest of the employees considered it insufficient, since to them the rhetoric of the change work did not comply with the reality. We argue that the main reason for this was the fragmentary meaning on the semantic level. Different anticipations circulated as the new management attached other meanings to everybody's involvement than did the employees. What the new management had expected was in conformity with the actual course of events, whereas, among the rest of the employees, the evaluation of the (alleged) realized involvement was negative.
To summarize, we can state that almost all individuals considered everybody's involvement to be an important and positive part of human resource and quality practice. On the other hand, only the new management felt that the practiced involvement was good, the reason being that different semantic interpretations were attached to the concept. What, then, is the fundamental difference between the new management and the rest of the employees?
Different worlds In the introduction, we argued that the concept of everybody's involvement had not been clearly defined in earlier research. We also explained that the logic of the world of ideas and
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the world of practice sometimes differs (Brunsson, 1993), which is why the empirical section was structured according to these dimensions. In this section, the argument is that the new management and the other employees of the CCV lived in different worlds, namely that they operated within heterogeneous cognitive frames, and that this was the main cause of the fragmentary sensemaking and the lack of contextualization.
The CCV's new management was externally recruited, and the new managers brought a number of ideas for modernizing the work. For example, they presented CCV 2002 as a paradigmatic shift. Even if they were well-experienced in managing the public sector, they had no specific experience in managing or working in the health and medical sectors. Consequently, they attempted to translate ideas that they knew functioned well in other sectors to the new organization. They lived in the "world of ideas".
The rest of the employees had no real knowledge of HRM and QM, either as concepts or in practice. The CCV had become known as a County Council opposing the New Public Management (Hood, 1995) ideas of change, wherein HRM and QM is a central issue (Power, 1997), that other County Councils had begun to use at the end of the 1980s (Skålén, 2002). Most of the employees based the sensemaking of CCV 2002 on the present practice - they lived in the "world of practice".
The two worlds were not united; contextualization did not come about. People continued to live in different worlds, meaning that they used different "languages" and different cognitive frames, attached different meanings to the concept of everybody's involvement and formed different attitudes toward HRM and QM ideas. The sensemaking became fragmentary as a result of the heterogeneous cognitive frames. However, this could have been avoided if the
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two worlds had been united, i.e. if the ideas had been modified to fit the existing practice. The present paper stresses the importance of the process that we call contextualization. Ideas must be adapted to fit the practice in order to create shared meaning.
Implications
As stated in the introduction, the need for contextualization and translation has previously been noted in research into organizational change in general (Czarniawska and Joerges, 1996; Rövik, 2000), but the concept has been weakly elaborated in a HRM and QM context. We believe that the sensemaking framework applied in this paper has added sharpness and precision to the concept of contextualization, as well as an understanding of how contextualization is realized. Concerning the latter issue, we would like to stress the importance of uniform enactments of reality, similar interpretations of the context and the organizational history, and sensegiving activities in order to reach shared meaning. Future research must focus on strategic change programs based on HRM and QM ideas where contextualization is realized in order to strengthen our conclusions. In addition to such research it would also be of value to understand the coupling between cognition and action in the context of strategic change based on HRM and QM. Our paper and the concept of contextualization deals with the coupling between ideas and shared meaning, but a common understanding of HRM and QM does not imply action in accordance with them, even though it is a precondition for such action.
The present paper is primarily devoted to organizational change, improvement of HRM and QM issues in particular. But we also regard our analytical distinction between normative and semantic sensemaking to be a contribution to studies of sensemaking. Our distinction corresponds with the distinction between "cold" and "hot" cognition in general psychological
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cognition studies (Klimoski and Donahue, 2001). According to the former view, person perception is rational, information-driven processes while the latter emphasizes normative, motivational and affective processes. Weick (1979; 1995) emphasizes cold cognition. We do believe, however, that it is important to include hot cognition in the analysis as well, which our distinction between semantic and normative sensemaking indicates. For future research, we recommend a more elaborated and explicit integration of theories on hot cognition with organizational sensemaking compared with the one provided here.
Our paper also has implications for management practice in organizations. Management must understand the need for contextualization. Managers not only have to acknowledge that strategic change in general, HRM and QM programs in particular, is time consuming, but also that a lot of time has to be spent on preparing for a change before initiating it. Management should concentrate more on paving the way for sensemaking rather than on marketing the impending changes internally. Shared meaning, on the semantic level, has to be realized before the actual change work starts. Management should also identify competent translators, not necessarily themselves, if HRM and QM change processes is to be realized. Translators are people who can bridge the gap between ideas and practice and who thus need to understand the ideas as well as be familiar with the world of practice. Such people are scarce. Lastly, in order for management to handle a sensegiving role, a coordinated view has to be created of just how idea and practice are to interact.
Notes
1
We are thus interested in both the process and effect of sensemaking, which can be seen as a partial departure from Weick's (1979; 1995) focus on process/organizing. There are, however, structural tendencies in Weick's theory as well; for example the concept of the cognitive frame discussed above. 2 We do not use, thus, the concept of fragmentary meaning in the same way as Ericson (2001). 3 According to some research into organizational culture, fragmentary meaning is a very natural thing (Alvesson, 2002, Martin, 2002; Parker, 2000), because complex organizations call for a high degree of differentiation of meaning contingent upon the various practices people are engaged in. A similar argument have been put forward by some of the proponents of QM, which have suggested its ambiguity is a great virtue (Wilkinson et al., 1998; Wilkinson and Willmott, 1995
. We also believe that complex organizations, especially in healthcare, are26
fragmented and in the ambiguity of QM and that both this issues can be good for the organization. However, in this paper, we focus on the idea of everybody's involvement in quality improvement work. Everybody's involvement concerns how the process of quality work should be organized throughout the entire organization. Thus, it is important to achieve, as we have argued, shared meaning, i.e. '?identical, or at least similar, meaning?' (we thus allow for some differentiation). On the other hand, we think it is natural and good that the effect (as opposed to the process) of quality improvement work in different departments (as opposed to the whole organization) differs significantly, since the department's objectives and tasks vary substantially. 4 Sweden's healthcare is geographically divided into 21 County Councils. Each County Council has a political assembly. The politicians of the CCV decided to embark upon quality improvement work but were not engaged in the actual quality work itself. Thus, the political level has not been studied in depth. 5 A complete account of the rules of the MCD analysis can be found in Silverman (1993).
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