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Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care.

Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed.

The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment.

There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians’ own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians’ perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.

The aim of this paper is to contribute to knowledge about the diversity of credibility arrangements in new audit spaces “in the margins” of auditing and the implications of such arrangements.

The paper is based on an in-depth qualitative study of the lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) rights certification run by the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL) during its first decade of operation. We have interviewed employees and studied documents at the certification units within the RFSL. We have also interviewed certified organizations.

We highlight two features that explain the unusual credibility arrangements in this audit practice: the role of beneficiaries in the organizational arrangements chosen and the role of responsibility as an organizing value with consequences for responsibility allocation in this certification. These features make it possible for the RFSL to act as a credible auditor even though it deviates from common arrangements for credible audits.

The RFSL certification is different in several ways. First, the RFSL acts as both a trainer and an auditor. Second, the trainers/auditors at the RFSL have no accreditation to guarantee their credibility. Third, the RFSL decides for itself what standards should apply for the certification and adapts these standards to the operation being audited. Therefore, this case provides a good opportunity to study alternative credibility arrangements in the margins of auditing as well as their justifications.