INVOLVED ACCOUNTING AND CONTROL IN HEALTH CARE

Different perceptions of management accounting and control systems

in the Dutch branch of nursing homes, homes for the elderly and homecare

Wil van Erp

Utrecht University of Applied Sciences / VU University Amsterdam

Padualaan 101, 3584 CH Utrecht

The Netherlands

E-mail: wil.vanerp@hu.nl

EIASM Public Sector Conference Edinburgh - September 2014

MCA-MACORG Symposium Paris - September 2014

Working paper

Please do not quote without permission by the author

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Abstract

The purpose of this study is to explore why and how Management Accounting and Control Systems
(MACS) enact and are enacted upon in the Dutch branch of nursing homes, homes for the elderly and
home care. In search for answers, this study chooses an actor-network theory (ANT) perspective
combined with case study research as research frames. Central theme in ANT is the theory of
translation. This theory offers opportunities for a close empirical inspection of how and why MACS
enact and are enacted upon by other actants in a complex set of sociotechnical relations. The theory
of translation is applied in a case study research at The Relief Group (TRG), a healthcare organization
which comprises a total of 10 nursing homes and homes for elderly. This case study shows how the
application of MACS expands both in numbers of employees involved and in amount of information.
Due to an increase in perceived environmental uncertainty and reorganization to a more
decentralized model of management all TRG management levels asked, to varying degree, for broad
application of MACS information in general and for non-financial information in particular. This
initiated a process in which MACS did not diffuse unchanged but was manipulated and aligned with
different interests of various stakeholders. At first sight, the TRG case study reveals MACS as a
boundary object. In second instance however, this study questions whether this epistemological point
of view, denoting the differences between the various TRG stakeholders as differences in
interpretation and perception, obscuring an optimal application of MACS, offers sufficient in-depth
understanding. Therefore this study draws on post ANT studies and chooses an ontological point of
view, delineating MACS as different objects, enacted in different sets of relations and contexts.

1. Introduction to the research question

The Dutch branch of nursing homes, homes for the elderly and home care, faces elementary
changes. The main developments are as follows. Firstly, to confine the national health care budget,
the central government has transferred several financial risks to care organizations. The system
dominated by expense claims is replaced by reimbursement systems based on performances.
Secondly, new government regulations concerning the extramuralization of clients with a low
indication for care pose a serious risk of real estate becoming vacant. Redeveloping real estate,
cutting back in residential capacity and the acceptance of corresponding financial losses seem
inevitable. And finally, the so-called thankful generation slowly gives place to a critical generation of
clients. This type of client asks for custom-made care. And vice versa, employees of care
organizations have to enhance their client-focus. The consequence of this demand driven
development is a differentiation of services.

To cope with these developments, managers in the care sector need extra management information.
Several studies have demonstrated a correlation between perceived environmental uncertainty and
the need for more sophisticated information from management accounting and control systems
(MACS): the higher the perceived uncertainty, the higher the need is for this kind of information
(Abdel-Kader & Luther, 2008; Merchant, 1990). Moreover, the opinion that custom-made care is not
possible without a decentralized, flexible and empowered management is widely held. A
consequence is a delegation of responsibilities to lower management levels, in particular team
managers. To live up to the new autonomy, these team managers are in need of MACS information
on team level.

However, there are no studies that explore the implications of the introduction of more
sophisticated MACS in the Dutch care sector. Introducing MACS in this sector is not just copying
management accounting practices from other branches. Several studies have indicated that MACS
interact with the conduct of business and organizational culture (Burns & Scapens, 2000; Busco,
Riccaboni, & Scapens, 2006; Collier, 2001). Implementation of MACS not only changes the

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organizational environment and corresponding processes, the structure and design of MACS are
moulded by their environment as well.

The main purpose of this research is to explore why and how MACS enact and are enacted upon in
the Dutch branch of nursing homes, homes for the elderly and home care. The deployment of MACS
in this branch increases. But how does this deployment evolves, what expected but also unexpected
outcomes and consequences are traceable in everyday practice and how can management learn
from this all? To find answers to these questions, this study chooses an actor-network theory (ANT)
perspective as research frame. Central theme in ANT is the theory of translation, which describes
how actants both human and non-human do not diffuse unchanged but are readjusted and
readapted in a context of interacting networks. In this perspective, deployment of MACS in the care
sector means that a process is initiated in which MACS enacts and is enacted upon by other actants
in a rhizome resembling clew of sociotechnical relations. Besides earlier versions of ANT, this
research is also inspired by post ANT studies which question the immutability of objects (Law &
Singleton, 2005; Mol & Law, 2001).

Largely adopted from Callon (1986b), five phases are distinguished to operationalize the concept of
translation. This framework of translation is applied in a case study: the TRG case. The choice for case
study research is founded in the possibilities it offers to penetrate deeply into an organization and to
realize a rich field study because the key to understanding practices lies in the careful tracing of their
constitutive activities (T. Ahrens & Chapman, 2007). The TRG case shows how the application of
MACS expands in both horizontal (extension on the same managerial level) and vertical direction
(extension to lower managerial levels). Main motives for these extensions are an increase in
perceived environmental uncertainty and reorganization to a more decentralized model of
management, impelling an interactive and broad application of MACS information in general and of
non-financial information in particular. Based on the TRG case study it is possible to depict MACS as a
boundary object. But it is doubtful whether an epistemological stand of view, denoting the
differences between the various TRG stakeholders as differences in interpretation, obscuring a
customized and optimal application of MACS, offers a feasible solution. That is why this study also
reconnoitres the so-called ontological turn (Watson, 2007), depicting MACS as different objects,
enacted in different set of relations and contexts (Law & Singleton, 2005).

This study is structured as follows. The next section presents a short literature review on different
modes of application of MACS and their corresponding effects. Next, ANT and post ANT are
explained. Subsequently the research methods used in this study are exemplified. This section
presents the research design. Next the case study and its results are presented. And finally this study
closes with concluding remarks and suggestions for future research.

2. Management Accounting & Control Systems

2.1. Relevance of MACS

By means of a memorable publication, titled Relevance Lost (1987), Johnson and Kaplan have
introduced a new agenda. The big challenge was and is how to align the new possibilities of
information technology with new accounting techniques in order to fulfil the new role of internal
business consultants (Burns & Vaivio, 2001). Widely supported is the conviction to broaden the
scope of MACS by including non-financial measures. Especially adoption of indicators like customer
satisfaction, on-time delivery and responsiveness to customer needs are seen as important drivers
for the use of non-financial measures (Abdel-Maksoud, Dugdale, & Luther, 2005). Bouwens and
Abernethy distinguish MACS information with a narrow scope versus information with a broad scope,
defining the latter as modern (Bouwens & Abernethy, 2000).

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Parallel to this development Burns and Vaivio (2001) describe another development. While new
information technology drives routine accounting tasks into centralized positions, management
accounting is becoming more decentralized (Burns & Vaivio, 2001). Last mentioned development
highly relates to perceived environmental uncertainty. The bigger this perceived uncertainty the
more decentralization of competences is inevitable and the more urgent the need for broad MACS
information in general and non-financial info in particular (Abdel-Kader & Luther, 2008; Abdel-
Maksoud et al., 2005; Merchant, 1990). A same positive correlation is identified between the
increase in relative customer power and the need for sophisticated MACS. This is in line with the
portrayal of the flexible firm by Mouritsen (1999).

Interesting is the suggestion that non-financial performance measures are highly related to what is
called upward communication (Abdel-Maksoud et al., 2005). This leads to the question how MACS
information is used. Naranjo-Gil and Hartmann make a clear distinction between a diagnostic versus
an interactive use of MACS information (Naranjo-Gil & Hartmann, 2007). Vaivio shows how non-
financial measurements promote interactive control systems (J. Vaivio, 1999). And recently, Chong
and Mahama (2013) conclude that interactive use of budgets has direct positive effects on team
effectiveness (Chong & Mahama, 2013).

2.2. MACS Change

The nature of MACS change causes a lot of discussion and research. Various studies show that the
diffusion of innovative management accounting practices is a process that is very hard to define (T.
Ahrens & Chapman, 2006). Others emphasize change in accounting is neither necessarily linear nor
foreseeable (Alcouffe, Berland, & Levant, 2008; Baxter & Chua, 2003). And some conclude change is
rather a drift of practices that move in time and space along the interactions of a multitude of actors
(Alcouffe et al., 2008).

Granlund (2001) signals a bulk of studies on management accounting change. Using ideas of Giddens
as well as institutional theory, his study aims to reveal how human, institutional, and economic
factors become intertwined in MACS change projects. Ferraro shows how the language and
assumptions of economics shape management practices. He explains how ideas of economist,
whether these ideas are right or not, are very powerful and can become true by modifying reality like
a self-fulfilling prophecy (Ferraro, Pfeffer, & Sutton, 2005; Ghoshal, 2005). And Vosselman on his turn
describes in detail the performativity of economic theory (Vosselman, 2014).

3. Theoretical framework

3.1. ANT

This study chooses an ANT perspective as research frame. This theory permits a close empirical
inspection of the behaviour of actors, who built networks in their pursuit to recruit allies and
mobilize artefacts to support their ideas and interests (Pipan & Czarniawska, 2010). ANT
distinguishes itself from other theories by considering both human and non-human actors on the
basis of equality. This is in line with the positive posture of ANT towards technology. In the present
social world people increasingly mix objects and society and therefore technoscience has become an
essential characteristic of our society, which justifies a so-called symmetrical anthropology (A.
Lowe, 2001b). These sociotechnical relations have to be investigated in order to understand the
teamwork between accounting systems and human actors in constituting contemporary
organizations (A. Lowe, 2001a).

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By tracing and studying the associations, ANT offers a possibility to explain how accounting
innovations diffuse. ANT explains diffusion by substituting diffusion for translation: an innovation
does not diffuse unchanged but is (re)adjusted and (re)adapted by the context of interacting actor-
networks in which it evolves and overcomes possible resistance (Akrich, Callon, & Latour, 2002b;
Callon, 1986b; B. Latour, 1987). The innovation is manipulated to align it with the multiple interests
of the actors (Akrich et al., 2002b; Alcouffe et al., 2008; Emsley, 2008). And during the process of
manipulation and alignment the inventors have limited control (Briers & Chua, 2001).

Callon (1986) unravels translation in four processes: problematization, interessement, enrolment and
mobilization. This enumeration does not stand for an imperturbable sequence. On the contrary,
these four processes overlap and interact with each other (Becker, Jagalla, & Skrbk, 2013; Dery,
Hall, Wailes, & Wiblen, 2013; Mhring, Holmstrm, Keil, & Montealegre, 2004). In the process of
problematization, a problem is identified and some proponents of change herald they have a solution
to offer in a first attempt to convince others. In the phase of interessement, the pioneers persuade
actors of the usefulness of the proposed solution by establishing connections between the interests
of those actors and the proposed solution. If successful, the outlines of a network of supporting
actors become visible. In the third phase the network grows and actors, both human and non-
human, are enrolled. The network becomes larger and stronger the more allies accept and take their
roles. In the fourth phase the solution is finalized after all relevant actors are mobilized and adopt
the innovation (J. Mouritsen, Larsen, & Bukh, 2001). By now the innovation can present itself as a
black box: a solid appearance which is not questioned for at least some time.

To subdue the variety and unpredictability of the process of translation, boundary objects can play
an important role in stabilizing and mediating diverse interests of actors (Briers & Chua, 2001; Star &
Griesemer, 1989). Boundary objects are objects which are both plastic enough to adapt to local
needs and the constraints of the several parties employing them, yet robust enough to maintain a
common identity across sites (Star & Griesemer, 1989). Despite having different meanings in
different sites, their nature and structure is distinctive enough to make these boundary objects
overall recognizable (Windeck, Weber, & Strauss, 2013).

ANT places calculations in a central place. Numbers and their inscriptions make it possible to mobilize
absent things and people in so-called centers of calculation (Justesen & Mouritsen, 2011; B. Latour,
1987; Robson, 1992). In line with this view it is possible to speak of MACS as actors because they
mediate relationships and stabilize associations between other people, devices and texts (B. Latour,
1992; Steen, 2010). Numbers are put to work through diverse inscriptions, not as representations of
reality, but as a tool that enables action, including action at a distance (Justesen & Mouritsen, 2011;
B. Latour, 1987; Robson, 1992; Vollmer, 2007).

Acknowledging the performative abilities of so-called centers of calculation, Quattrone and Hopper
(2001) contemplate accounting as creating centers of discretion. If accounting drives
organizational change it is not because it reproduces a new template for action but because the very
incompleteness of implementing and enacting its systems leads to accounting knowledge being
interpreted differently across organizational spaces and times. Accounting is not created according to
a central predetermined plan but rather by the interplay between calculations and discretion within
accounting practices (Quattrone & Hopper, 2001). Accounting as a practice does not lead
automatically to order and stability. Therefore it is in need of a managerial practice that creates
centers of discretion as well. Munro (1999) shows how management technologies like MACS
generate two functions: a durable calculative surveillance function and a flexible managerial
sanctioning function. The surveillance function produces records which are sanctioned as good or
bad, a process that performs managers as holders of power (Munro, 1999).

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 3.2. Post ANT

Like every invention, the development of ANT is not in the hands of its originators. ANT itself gets
translated (Gad & Jensen, 2010). Law and Singleton (2005) bring forward that in early ANT studies,
objects are thought of being too rigid and immobile. They pose the question ... even if we want to
think of objects as the effects of the enactment of sets of relations, those relations are a good deal
more variable than early versions of ANT tended to suggest? (Law & Singleton, 2005) In several post
ANT studies various versions of objects are distinguished (Gad & Jensen, 2010; Law & Singleton,
2005; Mol & Law, 2001; Mol & Law, 2004). The limited technical perspective pictures immutable
mobile objects like ships, circulating around the world and enabling long-distance control. The
second perception expands this narrow perspective by describing how these immutable mobiles
depend on a more or less stable and meaning providing network (Law & Singleton, 2005). In this
second perception ANT tends towards a functional managerialism (Mol & Law, 2001) to be used as a
tool to create methodological clarity in a context of messy objects (Law & Singleton, 2005). These
first and second perceptions are both epistemologically, meaning they presume that objects are
immutable boundary objects, looking complex and messy because people have different
perspectives. It is up to researchers to explain these different perspectives and so retrieve the real
object behind the interpretations (Law & Singleton, 2005).

This study aims for an extra performative dimension by changing from an epistemological to an
ontological point of view, meaning differences are no longer a matter of different perspectives on a
single object but the enactment of different objects in the different sets of relations and contexts of
practices (Law & Singleton, 2005). Law (2004) describes how we inevitably encounter multiplicity
when we study practice. But at the same time Law makes a stern distinction between multiplicity and
pluralism. Multiplicity ... does not imply that reality is fragmented. Instead it implies something
much more complex. It implies that the different realities overlap and interfere with one another
(Law, 2004). Analogous to Gad and Jensen (2010) one can say the complexity of MACS is a
combination of multiplicity there are many versions and images of MACS and fractionality or
partial connections they are related but not at all points or in all dimensions (Gad & Jensen, 2010).
In this context Watson uses the term fractional coherence (Watson, 2007).

The ontological point of view delineates fluid and fire objects. Fluid objects diffuse fluently as
mutable mobiles, both changing and staying the same, keeping a notion of family resemblance (Law
& Singleton, 2005; Mol & Law, 2001). Law and Singleton use the expression fire objects to emphasize
these objects are much more dynamic, more sporadic, less predictable and, yes, more discontinuous
than is suggested by the metaphor of a flow. This is why, for us, it is a fire object: it lives in and
through the juxtaposition of uncontrollable and generative Otherness (Law & Singleton, 2005). With
this quote an important concept in post ANT thinking is introduced: otherness. Law defines
otherness as: that which is neither present, nor recognizably or manifestly absent, but which is
nevertheless created with, and creative of, presence (Law, 2004). The issue starts with the simple
observation that not everything can be brought to presence and that by making things present it is
necessary to make others absent. Or as formulated by Law and Mol, the relation between presence
and absence is a link between a single present centre and multiple absent others (Mol & Law,
2001).

3.3. Conceptual framework

To put this theoretical elaboration to work, next step is to operationalize the concept of translation.
This study applies a slightly adjusted version of the classification of Callon. Instead of four phases,
this study depicts five phases by replacing the process of enrolment with that of MACS objectification
and connectedness. Table 1 provides a description of these five processes of translation. It is not new
to distinguish objectification or materialization as a separate process (Lindemann, 2014; Wagensveld,

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2013). This distinction makes it possible to trace the process of translation more accurately. After all,
the diffusion and materialisation of MACS objects is an important indicator for the enrolment of
MACS practices.

Processes Description
1 Problematization Problems are identified and presented by actants
Actants take on the role of initiator and proponent by informing potential allies and
actors how application of MACS can provide possible solutions.
Proponents make unsupported claims of MACS as provider of PEU reducing
information.
Proponents make unsupported claims of MACS as enabler of decentralisation of
authority.
2 Interessement Actants try to convince other actants that they will somehow benefit from MACS.
Arguments used to convince may vary significantly.
To convince other actants, a good story to legitimize MACS is told. These stories
include records on supposed MACS successes elsewhere outside the organization
and narratives of how the narrating actant himself benefits from the application of
MACS.
Actants indicate critical hesitation in relation to the recommendation of MACS;
indications of negative interessement.
3 MACS MACS concepts and MACS information are made tangible.
objectification Tangible MACS concepts and tangible MACS information are diffused, both in
horizontal and vertical direction within the organization.
4 Connectedness Actants are connected by accepting roles and active participation in the application
of MACS.
MACS are used by and shape the relations with other actants.
Actants try to draw other actants into a scheme of actions aimed at application of
MACS and enhance the connection of those actants already involved.
Actants give critical remarks and take a negative posture in relation to MACS
practices. MACS prove to be incapable to connect other actants. These actants are
or stay disconnected.
5 Mobilization Point of no return has passed. MACS practices have become unquestionable taken-
for-granted and their representing spokesmen are accepted as such.
MACS practices get institutionalized by reinforcing commitment to these practices
of shared goals and actions. This enhances the stabilization of the network.

Table 1: Framework of translation

4. Research methodology

4.1. Case study research

With previous theoretical considerations in mind, this study aims to answer to two research
questions:

1. Why and how do MACS enact and are MACS enacted upon by other actants in the case
organization, operating in the Dutch branch of nursing homes, homes for the elderly and
home care?
2. How can management in the Dutch branch of nursing homes, homes for the elderly and
home care learn from these translation processes of MACS in the case organizations?

The choice for case study research is founded in the possibilities it offers to penetrate deeply into an
organization and its culture, behaviour, experienced perceptions and mutual interactions. In order to

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increase the practical relevance of management accounting knowledge, Van der Meer and
Vosselman (2012) depict three forms of relevance. Besides the well known instrumental relevance,
they distinguish legitimative and conceptual relevance. Legitimative relevance relates to the way
knowledge is used to legitimize and enforce decisions (Nicolai & Seidl, 2010). Conceptual relevance
aims at theorizing the way decisions are taken. This study aims for a contribution to the conceptual
and legitimative relevance of management accounting practice.

In line with Bdard and Gendron, this study used three sources of data: semi structured interviews,
documents and observations (Bdard & Gendron, 2004). The interviewing took place in a sequential
way, meaning the first interview was analyzed after which the findings of this first interview were
used in the next interview and so on. Follow-up and probe questions were asked for further
explanation and clarification of initial answers (Bailey, 2007). And during all interviews, which lasted
between 60 and 90 minutes, an atmosphere was striven for to ease interviewees to bring up issues
not anticipated (Tucker & Parker, 2014). Acquired insights legitimized the possibility of adding new
questions or altering existing ones. In fact there was an intertwining relation between data collection
and data analysis (Marginson, 2004). The interviewing lasted until signs of saturation arise (T. Ahrens
& Dent, 1998; Marginson, 2004). After transcription of each interview, the interviewee was asked to
comment on the transcription.

4.2. Zooming in and zooming out

The sequence of research steps, as pictured in the previous section, was moulded according to the
two folded movement of zooming in and zooming out, as described by Nicolini (2009a). The zooming
in part related to a detailed study of practice. The second move, zooming out, aimed at theorizing
practice by deploying the theoretical framework as pictured above. This double movement is
necessary because descriptions of practice are often not enough and a coherent analytical stance is
necessary for the goal of outlining a coherent practice-based ontology (Nicolini, 2009a). The result of
this movement of zooming in and zooming out is a recursive procedure of field research and theory
refinement. Finally, after multiple iterations between theory and data, a theoretically oriented
interpretation can be extracted and then reported (J. Vaivio, 2008). This is in line with the idea of
Wagensveld and Vosselman (2012). Instead of depicting the theoretical domain as a central space
separated from practices, they explain how theory and practice are intermingled.

4.3. Computer assisted qualitative data analysis

To facilitate the tenacious process of analyzing and theorizing data, this research used the
opportunities of Computer Assisted Qualitative Data Analysis Software (CAQDAS) like ATLAS.ti.
Frequently mentioned advantages of using CAQDAS are the possibilities of handling huge amounts of
data in an orderly way. Moreover, this software helps researchers to demonstrate in a convincing
way the validity (Silverman, 2005) and reliability of their findings (Abernethy et al., 2005), offering
the possibility to leave an audit trail (Miles & Huberman, 1994).

In line with the conceptual framework, this research used corresponding conceptual codes. Next to
these conceptual codes, free codes were added in conformity with empirical data and suggestions,
which emerged during the coding process (Abernethy et al., 2005). To increase the objectivity of the
analysis both an interview protocol and a coding scheme were used (Malina & Selto, 2001).
Furthermore, two researchers independently coded several interviews, leading to an inter-rater
coding reliability up to 90%, well above the minimum norm of 80% (Miles & Huberman, 1994). In this
research, the co-occurrence and proximity rules, as described and applied by Malina and Selto
(2001), were used to trace and investigate in more detail the numerous associations.

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5. Case study: The Relief Group

5.1. Introduction

The Relief Group (TRG) is a healthcare organization which comprises a total of 10 nursing homes and
homes for elderly. In the annual report 2012, TRG accounts for a capacity of 1,253 intramural places
and 2,320 extramural clients. According to the P&L statement 2012, total revenues were 4,462,810
and the year was closed with a profit of 2,287,336. During the period August 2013 May 2014 a
total of 21 employees, ranking from board of directors to team managers, were interviewed. Besides
these interviews, 26 documents were consulted and analyzed to verify statements made during the
interviews. Furthermore several meetings for observation purposes were attended.

At the time the interviews took place a major reorganization was going on. Space to propagate the
so-called couleur locale was restricted in favour of unified transparent and efficient processes and
corresponding economies of scale. This reorganization had both a centralizing as well as a
decentralizing aim. In the back office, activities were clustered in shared service centers. On the
other hand, management structure was flatted by eliminating management levels, aiming for more
flexible client oriented care. The case description continues in accordance with the five phases of
translation, as depicted in table 1.

5.2. Problematization

In general, employees of TRG realized that external pressures and developments had far reaching
consequences for the organization. Governmental measures to contain the national healthcare
budget and new regulations concerning the remuneration of care services gave rise to many
uncertainties. Customary care provisions were under discussion whether they were applicable and
flexible enough to satisfy the needs of a new generation of elderly. According to these statements,
present reforms were not restricted to just budget constraints. One manager commented:

It is not just a question of how to economize spending. These kinds of questions presume
that the context stays the same. But this time the context is changing as well.

The call for more MACS information came from two sides. First of all, higher management asked for
more MACS information to make strategic choices to cope with the increase in perceived
environmental uncertainty. The continuous change in financial regulations, the dominant position of
health insurance companies and the emancipation of the client, created a slippery playing-field. To
navigate in this environment, the board of directors asked for more detailed financial information as
well as new types of information. At the time the interviews took place, investments were made in a
so-called strategic planning tool. This tool was supposed to provide an integrated and flexible picture
of future scenarios.

The second category of interviewees, who asked for more MACS information, consisted of managers
in lower echelons. These managers, in most cases team managers, were in need of MACS
information which corresponded with the decentralization of tasks and budgetary responsibilities.
Unanimously, interviewed team managers classified good functioning MACS as indispensable and
essential in order to intervene in time to prevent exceeding of budgets and stay in control.

5.3. Interessement

A first noteworthy facet in this process of interessement was the position of finance & control staff
employees. These employees were very explicit in their favour of the reorganization and the role

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MACS had to fulfil in the new setting. They criticized the inefficiencies in current practices and had
little or no sympathy for the arguments of location managers who clutched to the colour locale
principle. Their views contained a companywide central, streamlined and transparent back office on
one hand and flexible care services on the other. And to stay in control, these care services should be
connected with and controlled by the central office thanks to MACS. In general these employees had
a diagnostic and mechanistic view of how MACS should work.

In the process of interessement a second aspect attracted attention. All interviewees made extensive
use of legitimizing stories. These stories related to events and situations both inside and outside the
organization. In most cases these stories referred to preferable situations in which advanced
application of MACS played a conditional role. Higher management referred to successes of
colleague organizations which were considered to be the best practices in their branch. These
managers were also able to substantiate their points of view with reports from branch organizations
and consultancy firms. Lower management coloured their legitimizing stories with previous working
experiences or referred to internal situations which could be improved by the ongoing reorganisation
and the corresponding application of MACS.

In these legitimizing stories a bottom-up arrangement of operational processes was a trending topic.
But the direction of these stories was without any doubt top down. This was the third remarkable
aspect of this process of interessement. Upper management had to convince employees in lower
echelons that the organization in general and lower echelons in particular would benefit from
decentralization. At the time the interviews took place, higher and middle managers were convinced
of the reorganization and the role of MACS. At the level of team management unanimity made place
for mixed opinions.

With regard to the teams they managed, managers told stories of how difficult it was to raise interest
for MACS information among team employees. According to these stories, team members lacked the
knowledge and competences to fully comprehend these regulations. On the other hand, there were
team managers who drew a more moderate picture. They argued that team employees were
supposed to do their own housekeeping. If the layout of MACS at team level connected to the logic
of these housekeeping competences, these team managers considered empowering MACS
application at team level attainable.

At home my team members are able to book journeys, take out insurances, buy and use
smart phones, keep their own accounts. And here we have a kind of bookkeeping as well.

In this opinion, a multi level translation and application of MACS was a necessary condition to enable
self-regulation at team level.

5.4. MACS objectification

Many quotes of interviewees indicated that involvement with MACS increased, both with regard to
intensity as well as the number of employees. In fact, it was possible to discern two developments: a
horizontal extension of MACS information and a vertical extension. With regard to the horizontal
extension, higher management and staff employees described a vast growing output of management
accounting figures and an acceleration in the development and application of MACS during the last
two years. With regard to the design and implementation of this development, staff employees were
involved in several project teams. At the time the interviews took place, a list of 60 different projects
circulated. This list contained projects concerning human resources management, automation, sales
and marketing, real estate management and finance & control. Not only does this list illustrate the
size of the reorganization at TRG, it also highlights the range of developments of new management
information.

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There were many statements indicating MACS penetrated the organization in a vertical way also.
During the last two years team managers got acquainted with the so-called integral survey. During
the interviews, most team managers were able to select the relevant information to evaluate the
performances of their teams. Team managers, working at homes for the elderly and homecare, were
clearly more at ease and familiar with this information than their colleagues of nursing homes.

With regard to the extension of MACS in a vertical direction, the most remarkable example during
the interviewing period was the introduction of a digital dash boards at team management level.
They were introduced as substitution for the voluminous integral surveys. These dash boards aimed
at a more user friendly application of MACS information. Once fully operational, this dash board
should consist of four digital sheets, containing figures on productivity, personnel, clients and quality.

5.5. Connectedness

Both type and application of MACS information at TRG were diverse and divergent. With regard to
the different types of MACS data, information of a financial nature dominated. At higher
management level, figures on productivity, revenues and costs became more refined and detailed.
And at the same time, this information was supplemented with strategic financial info like long-term
forecasts and scenario analyses. On lower management levels, central figure was the so-called gross
margin. This was the difference between production revenues minus direct salaries. This indication of
productivity was widely used as performance figure and was prominent in the evaluation meetings of
team managers with higher management. Most team managers knew the specific gross margin
targets their teams had to meet:

I know I have to score 60% and I know which questions to ask when my performance is
below this percentage. I know which tools to use and I know how to check whether I have
enough space left.

Besides this gross margin and its determinative variables, team managers hardly bore witness of
further financial awareness and knowledge.

Besides financial data, the use of non-financial data was substantial. At high management levels
issues like quality of real estate and (long term) human resources mix figured prominently on the
agendas of managing directors. In their turn, team managers were predominantly occupied with the
amount of flexible labour contracts and the check whether personal care plans of clients were up-to-
date. Non-financial figures that gathered attention at all management levels were the percentages of
sick leaves and the ratios expressing client satisfaction and employee satisfaction. Both interviews
and corresponding co-occurrence analyses provided strong indications that at team management
level and team level non-financial MACS information was used more often compared to higher
management level. A likely explanation is the fact that non-financial figures like client-satisfaction or
number of medical incidents were more close to the perception of team employees than for example
productivity figures.

At higher management level, the use of financial and non-financial data for the purpose of
benchmarking was well known. TRG participated in the ActiZ benchmark, the leading benchmark in
this branch. In line with this external benchmark, the board of directors and location managers used
data of specific locations for internal benchmarking. This practice was not without discussion. As a
result of the presentation of these benchmark figures during a meeting of managing directors,
almost all managers questioned the validity of this internal benchmark.

11
Almost all team managers were familiar with the phenomenon of benchmarking. Even more, based
on the data as presented in the integral survey, they were able to compare the performances of their
teams with those of colleagues. Nevertheless, agendas and reports of team meetings did not record
any signs of the use of benchmark information. When asked, team managers stated that they used
this information only in the deliberations with their superiors. Towards their teams, these figures
were only used incidentally. Team managers explained that most team employees did not have any
connection with these figures what so ever.

Depending on the level of management, not only the type of MACS information varied, also the way
this information was used differed. At higher management levels a mix of diagnostic and interactive
control was observable. In particular interactive control took place in the meetings of higher and
middle management with lower management. At the level of lower management and in the
meetings of team managers with their team employees as well as with their superiors, the practice of
interactive control prevailed. To depict meetings with their superiors, team managers used
qualifications that indicated both rendering accountability as well as collegiality.

Of course I have to answer for my figures and performances. But that is not the way we
cooperate in this organization. Of course I explain to my superior what I have done and also
why. And then we consider together what went well and what went wrong and why and how
to perform better in the future.

Remarkable was the high co-occurrences of quotes coded with decentralization responsibilities,
employee empowerment, accountability and connect team management. These results
endorsed a successful progress of decentralization of authority to team management level. In
particular, team managers working in homes for the elderly and home care showed willingness to
apply MACS information as good as possible. Main obstacles in this aspiration were not the well
intended ambitions of these managers but lack of financial knowledge or, in their eyes, alienating
layouts of MACS artefacts.

To manage and ease their span of control and increase involvement of team employees, several
team managers explained how they used MACS information as illustration and legitimizing argument
in team meetings and individual counselling. In their experience MACS data were powerful and
legitimizing arguments.

Workload is of course a personal and subjective sentiment. I am glad I have objective figures
at my disposal now to demonstrate whether these feelings are justified or not.

Although interviewees did mention several ratios and indications to measure and monitor quality of
care, especially lower management did not make a connection between these quality figures and
MACS information. Admittedly, in their perception MACS information and quality were somehow
related but both sources came from different worlds nevertheless. Asked to what kind of MACS
information they used, interviewees mentioned all kinds of figures except for those related to
quality. And when questions were asked about the way perceived care was monitored, interviewees
naturally mentioned all kinds of quality indices they apparently did not think of when asked to
specify MACS information.

5.6. Mobilization

Hierarchically speaking, MACS had penetrated until and including the level of team management.
The trend of MACS information as one of the attention areas a team manager had to act on, was
irreversible. Whether MACS penetration could be extended to the teams was under discussion.
Especially higher management pointed to best practices elsewhere and concluded that a business

12
model, based on autonomous teams was feasible for TRG as well. Lower management and several
controllers were plainly sceptical. They questioned whether the competences of team employees
were sufficient. Overall, signs of connectedness of team employees with regard to MACS were very
limited.

Worth mentioning was the role finance & control staff employees pictured themselves in. Several
quotes indicated they felt that their role gained weight. This change paralleled the growth in MACS
information and corresponding questions from managers without a financial background. A
controller commented:

First it was head bookkeeping and I was the little assistant. Now it is concern controller and I
am one of the controllers.

The already mentioned integral survey could be considered as an institutionalized tool. The main
indicator of this survey, the gross margin, was widely mentioned and used as argument and
explanation. Also settled in was the so-called CQ index, a standard for client satisfaction. The
outcomes were discussed at all levels in the organization. Based on this index, locations and
departments were compared with each other. If necessary, proposals for improvement were defined
and attached to the so-called year plans and care treatment procedures.

The yearly budget cycle was also an accepted process. Although some employees questioned the
time consuming aspect of these processes, all agreed that involvement was a key element. During
the budget preparation, the HHM model played an important role. Based on the input of number and
weight of care indications, this model calculated the permitted direct costs on personnel in full time
equivalents. Although managers saw this model as a black box, the outcomes were considered
unanimously as legitimate starting point for the budget process.

6. Conclusions & Discussion

6.1. Conclusions TRG case

The TRG case study displays MACS as a phenomenon which enacts and is enacted upon, creating
different awarenesss. The MACS-we-do is neither a whole nor fragmented but rather a complex
mix of associative configurations. Nevertheless it is possible to draw some concluding remarks
concerning the effects of the application of MACS in this case organization.

First of all, the application and extension of MACS at TRG showed developments that were in line
with previous research on the application and employment of MACS. As demonstrated in many other
studies, the increase in perceived environmental uncertainty was also for TRG a major inducement to
deploy more advanced MACS. Even more, this same increase in perceived environmental uncertainty
impelled management of TRG to rearrange the organization to a more decentralized model. The way
MACS were modelled and shaped at TRG showed signs of a broad and interactive application of
information in general and of non-financial information in particular. Especially in lower echelons of
the organization, importance was attached to non-financial info.

Application and extension of MACS brought along a new vocabulary. Especially at higher
management levels, words like business case, efficiency, profitability, entrepreneurial and
business risks were quite common. Moving to lower management levels, this vocabulary was used
less or even caused offence. Some interviewees wondered whether this vocabulary was compatible
with their vocation to health care. They probably realized that these words introduced a new or

13
hidden curriculum, consecrating new competencies and performances (Oakes, Townley, & Cooper,
1998).

The description of MACS as centers of calculation was satisfactorily traceable in the TRG case study.
Although delegation of authority was commonly accepted, the necessity to stay in control was also
acknowledged especially by higher management and finance & control staff employees. This explains
why finance & control staff was stressing the importance of a uniform framework of MACS
information. These centers of calculation were also experienced as centers of discretion by
especially team managers. Examples of this perception are quotes made by team managers testifying
they were aware that MACS reports made their performances transparent to higher management,
causing a state of suspense among some interviewees.

6.2. From an ontological point of view

Based on the TRG case study it is possible to depict MACS as a boundary object. This indicates a
managerial approach which offers possibilities to picture MACS less messy and to create some clarity.
We need to explain [...] the different perspectives and so retrieve the real object behind the
interpretations (Law & Singleton, 2005). This is an epistemological approach, denoting the
differences between the various stakeholders as differences in perception and interpretation,
obscuring for TRG a customized and optimal application of MACS. But perhaps this managerialism
itself creates a part of the complexity and disarrangement. By shaping and ordering clarity and
distinction, certain problems, which do not fit in, risk being neglected and made invisible or othered
(Law, 2004). As alternative, it is also possible to take the so-called ontological turn, depicting MACS
as different objects, enacted in different set of relations and contexts (Law & Singleton, 2005).

How can MACS be differentiated as shape-shifting objects in this case study? To start with, there
was no single generally used name at TRG that encompassed MACS at TRG. Instead interviewees
used indications like integral survey, dash board and budget. Parallel to the different groups of
employees at least three different ways can be distinguished of how MACS act and are enacted.

The first category consists of employees of the finance & control staff. In their perception the most
significant contribution of MACS were comprehensive, reliable and accurate figures of a mainly
financial nature, which had disciplining and steering purposes. Both purposes necessitated the
utmost effort to make sure MACS figures were comprehensive, reliable and accurate. Once these
priorities were safeguarded, the question how to present these figures to the different users of
MACS information drew attention. In the efforts to disseminate financial information, a rational and
mechanic way of reasoning dominated. Although their intensions were upright, the reasoning of
these employees of the finance & control staff started from an accounting framework with little
understanding or consideration for other professional bodies of knowledge. Other aspects like the
legitimating and sanctioning application of figures, the policy stipulating role of both national and
local authorities as well as health care insurance companies and the mores of healthcare
professionals received less priority. The client resided somewhere in the background.

14
 Figure 1: MACS logic according to employees of finance & control staff.

The second category consists of higher management. Their involvement with MACS was primarily
driven by the steady increase in perceived environmental uncertainty. To determine what strategy to
choose to safeguard the continuity of the organization they expected MACS to facilitate the more
business- and client-oriented direction in which the branch in general and TRG in particular were
heading. They expected MACS to quantify risks and scenarios which included courses of action of
authorities, health care insurance companies and possible competitors. They used numbers less for
their representational faithfulness than for their numerous possibilities for future actions. Not
reliability or accuracy of figures was the main interest of these managers, but their legitimating and
sanctioning purposes. With regard to clients, the profile of the care needy client made room for
emancipated care consumers, with or without purchasing power and with or without the willingness
to pay for additional care.

15
 Figure 2: MACS logic according to higher management.

The third and last category consists of team managers who gained experience with MACS during the
last two or three years. Their perception of MACS culminated in the gross margin between revenues
and direct salaries. This figure was almost immediately translated in possible extra shifts or not. In
additional financial information these managers were not interested. However, they showed interest
in non-financial indicators related to the quality of health care because these indicators came more
close to the core of their motivation than financial indicators. But it was doubtful whether these
managers considered these non-financial figures as part of MACS. In their perception figures were far
from self-explaining. Behind each figure hid a discussion with their team employees. Although MACS
were supposed to bridge a distance bringing figures and their strategic translation close to
operating managers new distances were created as well. The bridging took place in a rational way
which went hand in hand with new distances in a mental and relational way. With regard to the
profile of clients, the care needing person dominated.

16
 Figure 3: MACS logic according to team management.

6.3. Implications and future research

Of a reality called MACS at least three different versions are pictured. These drafts show three
pictures of MACS, acting and enacted in contexts which have divergent priorities. These enactments
differ but are nevertheless related. This study does not supply ready-to-use conclusions. This is an
inevitable consequence of the choice of ANT as methodology. Moreover, insights gathered from the
analyses of the TRG case study cannot be used to judge other practices. Neither does this study
indicate how to bridge aforementioned mental and relational distances MACS created in the TRG
case. Some kind of cross-functional integration between employees of finance & control staff and
team managers seems to be a plausible start of an answer that is beyond the scope of this study.

What can we learn from all this? First of all, this study points out that MACS applications introduce a
new set of tensions. This study does not provide an answer to the question whether this new set is
better than the previous one. However, this research provides a tailor-made description of how in
this particular case the MACS network unfolds. Instead of describing an accounting method which
isolates each variable and is incapable of articulating links and tensions, this study produces rich
stories of lived MACS practices and associations. The descriptions show MACS are not an isolated
tool or instrument employing solely functional and neutral knowledge. On the contrary, all managers
and professionals involved ought to realize that MACS provide theory- and value-laden information,

17
which effectuates a range of diagnostic and interactive interventions and manipulations. In fact the
approach, as chosen in this research, shows that there are many choices and possibilities offered.

In a first attempt to deduce lessons how to manage these unforeseen and self deploying MACS
practices, four considerations come to mind. In the first place one has to realize that organizations
are always in a process of change. Even more, as Tsoukas and Chia illustrate, change can be seen as
the normal condition of organizational life (Tsoukas & Chia, 2002). In managing these continuous
changes, managers need to be aware of both the unavoidable irruptive power of events and of the
fact that actor-network changes constantly occur in different spaces and at different times (Lancione
& Clegg, 2013).

Secondly, one has to realize the far reaching impact of non-human aspects in organizational life.
Several studies show how for example technologies intermingle with and enact upon human life in a
profound, complex and almost inimitable way (Latour, Hermant, & Shannon, 1998; Thrift & French,
2002). In the case of this study, not layout and content of MACS were the important issues at stake
but the effects and practices these systems evoked.

As the TRG case shows, not all actants involved were convinced of the added value of MACS.
Consequently, these actants hesitated to connect to the corresponding actor-networks. If not all
relevant actants connect to the same actor-network, the enacting movement could falter and dilute.
To manage this risk, one should monitor who connects and who does not for what reason. This study
shows that there are numerous reasons for not getting connected.

In line with the previous paragraph a fourth and last consideration can be mentioned. This though
builds on the co-occurrence analyses which showed strong associations between the codes
decentralization responsibility, employee empowerment and accountability. These associations
indicate a process which Adler and Borys (1996) call enabling formalisation. Research indicates that
this enabling type of formalization encourages motivation based on identification and integration,
meaning the person involved internalizes both goals and discipline necessary to reach them (Adler &
Borys, 1996; Deci & Ryan, 2000; Gagn & Deci, 2005; Lam & Gurland, 2008; Van den Broeck,
Vansteenkiste, De Witte, Lens, & Andriessen, 2009; Vansteenkiste et al., 2007). Although possible
connections with these psychological studies are beyond the scope of this research, it is not unlikely
that these studies might provide possible leads how to foster earlier mentioned associations with
systems like MACS.

To conclude, there is no holy formula to manage change. This study shows change is only
manageable to a limited extent and is in desperate need of an awareness requiring a de-
centralization of the selves that presume change agency in order to appreciate the others human
and not-human that shape as much as these managers (think they) do (Lancione & Clegg, 2013).

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