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Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care.

The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data.

The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers’ strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements.

Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers’ multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.

The internal customer concept is used with different definitions and purposes in research and in practice – an ambiguity with implications for both scholars and practitioners. The purpose of this study is, therefore, to explore the representation of the internal customer concept in quality management literature and reflect on how the user may affect collaboration in health-care processes, in particular between a service function and health-care staff.

A review of the internal customer concept in the literature, followed by a conceptual discussion based on previous studies and theories of organizational discourse.

Three predominant types of relationships related to the internal customer concept were found. The study shows that the ambiguity in the use of the concept may have consequences for the interpretation and application of research results. Potential undesirable consequences with regard to collaboration in processes are discussed.

This study contributes to a new understanding of the internal customer concept in research and practice. As collaboration within and between organizations is increasingly required in many parts of health care, careful considerations become necessary regarding concepts used for relationships to avoid sub-optimization and “us-versus-them” thinking and to strengthen trust-based relationships.