Measuring what matters: governance challenges in defining follow-up priorities in complex healthcare systems

Performance measurement plays a central role in governing healthcare system reforms, yet defining what should be monitored is often challenging in complex and decentralized systems. Rather than functioning as neutral tools, performance indicators shape how reform priorities become visible and governable within reform processes. While previous research has examined the design and effects of performance measurement systems, less is known about how follow-up priorities are negotiated when broad reform ambitions are translated into local governance. This study explores how municipal stakeholders negotiate what should become measurable during the implementation of a large-scale healthcare reform.

An interpretive descriptive approach was used. Data were generated through nine stakeholder workshops involving 191 participants across municipalities in Västra Götaland County, Sweden and analysed using an abductive thematic analysis. Participants included politicians, managers, civil servants and healthcare and social care professionals. The workshops explored existing indicators, information gaps and the conditions required for meaningful follow-up of the ongoing transition towards Close Care, a national reform aiming to strengthen primary care and develop more person-centred services.

Four closely related empirical patterns were identified and, through abductive interpretation, synthesized into a conceptual framework comprising normative, conceptual, infrastructural and epistemic conditions shaping the feasibility of measurement-based governance. First, stakeholders negotiated why, for whom and how measurement should be used, reflecting tensions between accountability, quality improvement and learning. Second, conceptual ambiguity regarding the reform's governing object made it difficult to determine what should be measured. Third, fragmented data infrastructures limited the availability and comparability of indicators. Fourth, limited epistemic capacity constrained how available data could be understood and used for governance and improvement.

Rather than viewing tensions between reform ambitions and measurement feasibility as implementation failures or resistance to measurement, the findings suggest that such tensions are inherent features of governing complex healthcare systems. By examining the governance processes through which "what matters" is negotiated before becoming measurable, the study highlights measurement itself as a central governance process. Before performance measurement can guide governance, organizations must establish the normative, conceptual, infrastructural and epistemic conditions that enable measurement to become meaningful, actionable and ultimately performative.