Guest editorial for the special section on “Operational Excellence and Quality Improvement in Sweden”

Citation

Cronemyr, P. and Fundin, A. (2024), "Guest editorial for the special section on “Operational Excellence and Quality Improvement in Sweden”", International Journal of Lean Six Sigma, Vol. 15 No. 6, pp. 1157-1161. https://doi.org/10.1108/IJLSS-10-2024-259

Quality management and operational excellence have a long tradition in Sweden, embedded in national values of democracy and pragmatism. Early pioneers of Swedish Quality practice and research were Lennart Sandholm, Bo Bergman and Bengt Klefsjö. Today many researchers and practitioners carry the flame. Historically, Swedish products were well-known for high quality, today the quality work has been expanded into sustainability and societal satisfaction. It has been included in many parts of the processes of businesses and public organisations to the extent that quality management has often been incorporated into the normal way of working, sometimes making it almost invisible. Still, the basic values of quality management are as important as ever: focus on customers (now expanded to the stakeholders of society), work with processes, base decisions on facts, improve continually and, last but not least in Sweden, let everybody be committed. All of these are surrounded by management commitment and systems thinking.

This special issue highlights the historic development, the current state and the future challenges of QM and OPEX in Sweden, looking at different types of processes and organisations. As pragmatists do, Swedish practitioners often use a mix of several QM and quality improvement methods and tools, not only Lean and Six Sigma. The mix often consists of old and new methods that “works well for us”. Not only success stories are presented but “what went well”, as well as “what did not”. Failure is a gold mine, as Joseph Juran said, and learning from mistakes is a very Swedish way of working, based on a culture of low prestige and to strive for continuous learning and innovation. Also, the level of digitalisation is high, as it can make processes faster and more reliable, and at the same time, facilitate customisation of products and services in a structured manner. During such a transformation questions arise, are we moving too fast or maybe not fast enough?

In the first article “Swedish quality: A historical perspective and reflections for the future”, distinguished professors Bo Bergman, Bengt Klefsjö and Lars Sörqvist explore the history of Swedish QM since 1949 and also offer some important lessons for further quality improvements in Sweden and elsewhere. They explain that since the modern quality movement fits well into the Swedish national culture, several corporate leaders have utilised the cultural characteristics in Sweden to achieve a successful quality transformation. Swedish national culture differs from other countries in several ways. Swedes have a strong belief in individual rights and independence, a deep respect for laws and rules and a high level of trust in public institutions. Swedish society is also characterised by relatively short power distances, which means less hierarchical organisations and extensive informal communication. Sweden was one of the first countries to establish academic research and education in this field at the university level with professorships specifically focused on quality and quality improvement. During several decades there was close collaboration between Swedish scholars and Joseph Juran. During this time Swedish QM, mainly practised in the private sector, evolved from “inspection quality” to “full TQM”. Some of the most successful companies were IKEA, Ericsson, SKF and Scania.

However, as QM practices became more advanced and complex, there was frustration among QM practitioners and researchers that Swedish industry managers did not fully understand TQM. Hence, several government-funded programmes for QM research and education were started. The authors also describe that modern quality management has faced problems in terms of being accepted and applied in the Swedish public sector. Even though a healthcare quality improvement movement emerged in Sweden already in the late 1990s, there is an increasing discussion in the Swedish debate concerning a quality crisis in the Swedish public sector. They argue that transferring quality management ideas from the private sector to the public sector must be done carefully and sometimes with terminological adaptations. The poor results in the Swedish public sector are often blamed on new public management (NPM), which is now viewed upon as “a very bad translation and application” of TQM in the public sector. Success requires both trust and a fact-based approach, of which NPM seems to lack both. There are concerns, similar to earlier concerns about Swedish industry managers, that current Swedish leaders and politicians do not fully understand the meaning and importance of successful quality management and not take quality issues sufficiently seriously. Instead, the authors often see a narrow-minded leadership focusing on short-term results, trendy methodologies or expensive foreign management consultants promising to solve the problems.

It is a paradox that a major part of Swedish research into QM during the last decades has been about QM in the healthcare sector, and still, there are problems as described above. Some things are just not the same in the private and in the public sectors. What are they? The question is should, and if so how could, QM be applied in healthcare? That is what several of the following articles are about.

In “Important drivers for customer satisfaction – a Swedish crisis reflection”, Jacob Hallencreutz, Johan Parmler and Love Westin, describe the results from measurements of customer satisfaction during two decades up until now. Measurements were carried out in four service sectors, but not healthcare. Based on the data and previous research they conclude that, in times of crisis, new trends in consumer behaviour emerge. Since the last ten years, product quality has been substituted by service quality, as most important to customers. In service quality, speed, simplicity and convenience are key elements.

Even though the study was not conducted in the healthcare sector, the customers are most likely also citizens and patients. So, given the problems of QM in health care, as described above, could the need for speed, simplicity and convenience in health care be fulfilled in the complex and rigid organisations and systems of the health-care sector? Could it be part of the problem?

In “Quality Improvement development in Swedish Healthcare and Welfare Services”, Ann-Christine Andersson presents a major literature review of most of the research conducted on QM and Quality Improvement (QI) in Swedish Health care, carried out during the last three decades. Andersson categorised 276 papers, dissertations, books and chapters on the subject. Andersson concludes that QI is today an established concept in healthcare and welfare organisations encompassing the domains of safety, person-centeredness, effectiveness, efficiency, equity and accessibility. Today, all Swedish healthcare regions use QI based on systematic improvement work. Andersson found that for successful QI, both traditional professional knowledge and QI knowledge are required to reform and improve healthcare. While professional knowledge in health care is taken for granted, how good is the QI knowledge and is it suited for such organisations? In her overview synthesis, Andersson found six focus areas, where one is Leadership and learning. Is there a quality culture that promotes this? For example, staff's perspective on the relationship between organisational culture and quality in relation to value conflicts when introducing IT systems as tools were highlighted. Andersson concludes that participation and coproduction are an increasing trend, creating better conditions for health care and welfare in the future. But better for whom?

In “Paradoxical tensions during industry 4.0 integration within healthcare: Managing tensions for quality improvement”, Daan Kabel, Jason Martin and Mattias Elg explore the paradoxical tensions that arise for health-care organisations when integrating Industry 4.0. Once again we see how a topic from private sector, Industry 4.0, is applied in the public sector. Industry 4.0 is characterised by digitalisation and the adoption of digital technologies into organisational processes. Sometimes Industry 4.0 is called Healthcare 4.0 when applied within healthcare. The authors emphasise that there are no one-size-fits-all solutions for organisations when implementing different digital technologies, some paradoxes need to be addressed. They found that some organisations fail to integrate Industry 4.0 because of a lack of a strategic plan that supports the adoption of digital technologies. While the implementation of Industry 4.0 promises several benefits, such as improved decision-making, process efficiency and enhanced services, not all organisations are equipped to integrate it. Industry 4.0 demands a dynamic and flexible strategy and the coordination among multiple stakeholders. They suggest that the paradox of applying both an inside-out orientation and an outside-in orientation could be solved by a balanced strategy by a set of techniques: meta-routines, enrichment, switching and partitioning techniques. They also mention that a dynamic capability approach represents an evolved form of the inside-out orientation, emphasising the critical need for adaptation, innovation and responsiveness to changes in the external environment. We will return to that topic in the last article.

In “Developing value-based leadership for sustainable quality development: a meta-analysis from a study of Lean Manufacturing”, Kristen Snyder, Pernilla Ingelsson and Ingela Bäckström explore how leaders can develop value-based leadership for sustainable quality development in Lean manufacturing. The study was carried out as a qualitative meta-analysis of data from a three-year project on Lean manufacturing, previously described in five papers by the authors.

“Where are the people”? Asked an employee, after the leadership team delivered a presentation about the new strategic plan. Perplexed at first, the leadership team soon realised that in their care to form a strategic plan for the coming five years, they had failed to incorporate the company’s number one asset: the people. Management took for granted that the people were already embedded in the plan given their employment. The authors continue: quality management initiatives often miss the mark on achieving excellence because leaders focus on tools and processes and lack an understanding of organisational culture and the value of the people. This challenge in the changing landscape of business in the fourth industrial revolution. QM needs to build on the human dimension to achieve sustainable value, both for organisations and society. They argue that leaders too often focus on structure and process at the expense of understanding the culture, and leadership behaviours impact the culture of the organisation. The job of leaders is to make values visible through behaviours. Establishing a new or modified organisational culture is a long-term process. In their analysis, the authors used the Shingo Model which identifies three essential insights for leadership: (1) ideal results require ideal behaviours, (2) purpose and systems drive behaviours and (3) principles inform ideal behaviour. They found that by focusing on behaviours and values, the leaders were able to better align the systems, tools and processes with work culture, which is a challenge for many organisations. They agreed with Shingo who claimed that when systems are properly aligned with principles, they strategically influence people’s behaviours toward the ideal. The study demonstrated a strong relationship between organisational culture and business excellence and hence the connections between leadership, values and QM, which the authors claim are far too often missed.

Is not that the main problem in many of our QM and QI endeavours? “Hard” issues, like process maps, systems, tools, measurements and organisational responsibilities, take over “soft issues”, like leadership, behaviours and culture. Both need to be aligned to fulfil the strategic goals of the organisation.

In “From Perception to Practice: Quality management in multinational company from a Swedish perspective”, Promporn Wangwacharakul explores the interplay between levels of cultures and aspects of QM when managing quality in a multinational company. The data were collected through semi-structured interviews with quality managers in seven multinational companies’ facilities situated in Sweden and related document study. All multinational companies claimed to have strong focus on quality and substantial experiences with QM, but, they had different levels of experiences of international cooperation. The study showed that the national culture of subsidiaries in the companies influenced employees’ perception of QM principles and that miscommunication and varying levels of employee empowerment hindered the development of a common understanding of quality.

Once again we see importance of culture and the awareness of culture. We should probably not try to change and harmonise national cultures, but being aware of differences may help to cooperate between departments, companies and nations.

In the final article “Pursuing sustained competitive advantage through the use of process management”, Priscilla Huldt Navarro and Linnea Haag combine the research fields of quality management and dynamic capabilities to explore how process management can support organisations, especially small and medium sized enterprises, in pursuing sustained competitive advantage, referring to advantages that differentiate organisations from their competitors, that are difficult to imitate or replicate and that companies purposely and actively sustain over time.

The topic of process management is well known and established within QM, but several researchers have advocated for adaptations in process management to enable organisations to react in a faster and more flexible way to their surroundings, thereby enhancing customer and societal satisfaction. Furthermore, it has faced criticism for potentially constraining flexibility and creating a trade-off between efficiency and innovation. The authors present a case study and use a dynamic capability lens in the analysis. Micro-foundations are identified, which can enhance or inhibit the development of dynamic capabilities when implementing process management. When doing so, process awareness and understanding of the methodology are critical for a successful implementation. Furthermore, the appropriate organisational structure for dynamic capabilities needs to be organic and responsive. The suggested adaptions of process management not only make organisations more flexible and agile, but they also connect QM, through the application of process management, to the strategic goals of the organisation. Strategic goals and the goals for the processes of the organisation is the basis for the connection between processes and dynamic capabilities. As mentioned by other authors in this issue, this link has often been a weak link of QM.

In this article we also come back to the question of leadership. The authors claim that process orientation and customer focus require management commitment, i.e. that management needs to motivate and encourage the rest of the organisation. This links to the article by Snyder, Ingelsson and Bäckström and may suggest a possible path of development for the healthcare organisations with many problems mentions by Bergman, Klefsjö and Sörqvist.

In the evolution of QM and quality improvements, focus has changed from product to customer and, lately, society. One major part of society that has not had the top priority has been the employees. In private organisations economic profit is the over-all goal, based on high level of customer (and lately societal) satisfaction, which is created by satisfied and motivated employees. In the public sector satisfaction of customers, i.e. patients, students and citizens, is the main goal, but the organisation has to stay on budget, decided by politicians. When the economic resources are scare, it often affects the work environment of the employees.

Swedish quality is well-known and will probably continue to be so. The next step in development of QM and quality improvements may be more focused on employees, as they are crucial components in the development towards societal sustainability.