In healthcare, technologies have the potential to provide new and useful knowledge for both patients and healthcare professionals. However, to realize their full potential and become truly useful, these technologies must be integrated into a broader healthcare service ecosystem that includes a wide range of actors. Successfully integrating such technologies requires the coordination and collaboration of a diverse set of such actors, including healthcare professionals, public actors, and market actors. Understanding the challenges along the institutionalization process of new and useful knowledge derived from technology is essential for advancing service innovation within healthcare service ecosystems.

According to Service-Dominant (S-D) logic, innovation typically begins with the collection and refinement of ideas from a diverse set of actors. While the inclusion of this broad set of actors is essential for innovation, it can also lead to institutional conflicts or frictions between actors. These conflicts arise from competing or sometimes opposing ideas, which can be traced to multiple institutional logics—deeply ingrained norms, beliefs, and assumptions—that shape how actors frame and adopt ideas. Institutional logics also guides actors in how technologies, as carriers of ideas, are adopted, implemented and used. Institutional conflicts are critical obstacles to overcome during the innovation process; however, they are often overlooked. Studying these conflicts is particularly important because, in the worst-case scenario, they can become so severe that they block innovation within service ecosystems. The purpose of this thesis is to contribute to the understanding of service innovation that accounts for the multiplicity of institutional logics within a healthcare service ecosystem. Specifically, this thesis discusses a set of institutional conflicts and investigates how actors resolve or mitigate them. In this thesis, the actors proposing ideas for technology, including its integration within a healthcare service ecosystem, are broadly categorized according to three institutional logics: medical professional, market, and public welfare.

The results of this thesis discuss five recurring conflicts: differing meanings of technology, conflicting assumptions about medical responsibility, tensions in decision-making procedures, legal challenges related to resource ownership, and different expectations for resource sharing. To mitigate or resolve these conflicts, four recurring reconciliation strategies are identified: compromise, confrontation, mobilization, and avoidance. This thesis provides actionable recommendations on how to effectively manage institutional conflicts within a healthcare service innovation context. It makes three key contributions to service innovation research within the conceptual framework of S-D logic. The first theoretical contribution is the development of a novel typology of institutional reconciliation strategies. The second explores the factors that influence the success or failure of innovation within service ecosystems. Lastly, the managerial contribution identifies contemporary enablers and constraints that drives service innovation in healthcare ecosystems.

Inom hälso- och sjukvård har medicinsk teknik en möjlighet att ge ny och användbar kunskap för både patienter och vårdpersonal. För att denna teknik ska kunna bli användbar måste den integreras i vårdens ekosystem, vilket påverkar ett stort antal aktörer. För att lyckas med integrationen av tekniken i vårdens ekosystem krävs koordinering och samarbete mellan vårdpersonal, politiska aktörer, beslutsfattare och privata marknadsaktörer. Att förstå de utmaningar som uppstår vid etableringen av teknik är avgörande för att aktörer ska kunna driva innovation inom vårdens ekosystem.

Inom tjänsteforskning börjar innovation ofta med att insamling och förfining av idéer från ett brett spektrum av aktörer. Även om inkluderingen av detta breda urval av aktörer är avgörande för innovation, kan det också leda till institutionella konflikter, det vill säga spänningar och friktioner mellan aktörer på grund av konkurrerande eller ibland motsatta idéer. Dessa konflikter uppstår från flera institutionella logiker—djupt rotade normer, värderingar och attityder—som formar hur aktörerna förstår och införlivar idéer. Institutionella konflikter utgör således hinder att övervinna under innovationsprocessen; men i forskningen brukar de ofta förbises. Att studera dessa konflikter är därför särskilt viktigt, eftersom de i värsta fall kan bli så allvarliga att de blockerar innovation – etablerandet av teknik i form av ny kunskap – inom vårdens ekosystem. Denna avhandling bidrar till förståelsen av innovation som beaktar mångfalden av institutionella logiker inom vårdens ekosystem. Mer specifikt diskuterar denna avhandling institutionella konflikter och undersöker hur aktörer löser eller mildrar dessa. Aktörer som föreslår idéer för teknik, inklusive dess integration inom vårdens ekosystem, kan kategoriseras utifrån tre institutionella logiker: medicinsk, marknad och offentlig välfärd.

Avhandlingens resultat diskuterar fem återkommande konflikter: olika tolkningar av teknik, motstridiga antaganden om medicinskt ansvar, spänningar i beslutsprocesser, juridiska utmaningar relaterade till resursägande och olika förväntningar på resursdelning. För att mildra eller lösa dessa konflikter identifieras fyra återkommande strategier: kompromiss, konfrontation, mobilisering och undvikande. Denna avhandling ger konkreta rekommendationer om hur institutionella konflikter som påverkar tjänsteinnovation i en hälso- och sjukvårdskontext kan hanteras effektivt. Avhandlingen presenterar viktiga bidrag till forskningen om tjänsteinnovation. Det första teoretiska bidraget är utvecklingen av en ny typologi av strategier för hur aktörer kan hantera konflikter. Det andra bidraget undersöker de faktorer som påverkar framgång eller misslyckande i konflikthantering och innovation inom vårdens ekosystem. Det praktiska bidraget riktar sig till beslutsfattare och politiska aktörer i vårdens ekosystem och hur de kan främja innovation.

Purpose – The integration of industry 4.0 has become a priority for many organizations. However, not allorganizations are suitable and capable of implementing industry 4.0 because it requires a dynamic andflexible implementation strategy. The implementation of industry 4.0 often involves overcoming severaltensions between internal and external stakeholders. This paper aims to explore the paradoxical tensions thatarise for health-care organizations when integrating industry 4.0. Moreover, it discusses how a paradox lenscan support the conceptualization and proposes techniques for handling tensions during the integration ofindustry 4.0.

Design/methodology/approach – This qualitative and in-depth study draws upon 32 semi-structuredinterviews. The empirical case concerns how two health-care organizations handle paradoxical tensionsduring the integration of industry 4.0.

Findings – The exploration resulted in six recurring technology tensions: technology invention(modularized design vs. flexible design), technology collaboration (automation vs. human augmentation),technology-driven patient experience (control vs. autonomy), technology uncertainty (short-termexperimentation vs. long-term planning), technology invention and diffusion through collaborative effortsamong stakeholders (selective vs. intensive collaboration) and technological innovation (market maintenancevs. disruption).

Originality/value – A paradox theory-informed conceptual model is proposed for how to handle tensionsduring the integration of industry 4.0. To the best of the authors’ knowledge, this is the first paper to introduceparadox theory for quality management, including lean and Six Sigma.

Cost-effectively capturing and understanding customer needs allows a firm to stay synchronized with the market, to stay ahead of competitors, and to enable service innovation. Traditional qualitative market research methods, such as interviews and focus groups are well-known methods for identifying and capturing customer needs but can be costly, tedious, time-consuming, and can require intensive collaboration with customers. As social media platforms become increasingly central in customers' daily lives, they can become valuable sources for identifying and capturing customer needs. The process of using social media content in market research is called netnography. In this thesis, the instrumental case to study customer needs is from a healthcare context.

The healthcare system is an interesting illustrative case because it struggles with satisfying customers' needs – due to the difficulty of delivering high-quality services across multiple channels and devices, to secure customers' data, and to offer customized human-centred care. Against this backdrop, the purpose of this thesis is, by taking on a customer-centric view, to contribute to a better understanding of the quality of digital services. To fulfil this purpose, two research questions are formulated and answered. The first research question concerns the differences and outcomes between netnography and focus groups when capturing customers' needs. Formally, it is formulated as: What are the differences and outcomes between netnography and focus groups when capturing customers' needs? The second research question concerns the customer value cocreation activities and qualities necessary in a digital healthcare service to satisfy customers' needs. Formally, it is formulated as: What customer value cocreation activities and qualities satisfy customers' needs in a digital healthcare service? Taking customer-centric views, findings from three papers and empirical data from a survey, netnography, and a focus group project are used to shed light on the theoretical entity of customer needs – which is the unit of analysis.

The contextual differences between netnography and focus groups are related to the embedded rules, norms, and space-time conditions. Such conditions pattern the information about the service and customers' needs. The netnography method captures sociohistorical-patterned information about more critical events, and realistic and negative service encounters. When capturing customers' needs, the netnography method captures more dominant, unmet, and actual (real time) needs. The focus group method captures transcultural-patterned information about more positive, memorable, and ordinary service encounters. When capturing customers' needs, the focus group method captures more evenly distributed, met (satisfied), and memorable needs. Most surprisingly, both methodologies capture, almost, the same needs. However, the proportion of needs discussed across the two samples is significantly different. The netnography method did not capture the needs of "system capacity" and "access". The focus groups method did not capture the need of corporate "responsibility".

A conceptual model is illustrating four value creating activities and quality bundles necessary to deliver customer-determined benefits. The conceptual model is a synthesis of the customer journey, perceived electronic service quality and value concept – and provides a new, integrative view of customers' perceptions of digital healthcare service. The model gives a comprehensive understanding of what makes service journeys superior and supportive, and how service providers can optimize the customer experiences – which includes perceptions of personal health and well-being. This thesis offers several important conclusions for quality management. Broadly speaking, the thesis raises an awareness of the importance of the continuous variables – rules, norms, and space-time conditions – which pattern research data or information about the service and customers' needs. The conceptual model can guide managers on how to allocate resources – and that is to design high-quality service encounters.

Tjänsteinnovationer möjliggörs genom att kostnadseffektivt fånga och förstå kunders behov. Traditionella kvalitativa marknadsundersökningsmetoder, såsom intervjuer och fokusgrupper, är välkända metoder för att identifiera och fånga kundbehov men kan vara kostsamma, tidskrävande och kan kräva intensivt samarbete med kunder. I takt med att sociala medieplattformar blir alltmer centrala i individers dagliga liv kan också de bli värdefulla källor för att identifiera och fånga kundernas behov. Processen att använda innehåll i sociala medier i marknadsundersökningar kallas nätnografi. Men hur står sig de traditionella metoderna mot nya sätt att fånga kundbehov?

Sjukvårdssystemet är ett intressant och illustrativt fall eftersom det är en komplex tjänsteverksamhet där många olika perspektiv behöver hanteras. Mot denna problematik är syftet med denna licentiatavhandling att förstå kundernas behov i en digital sjukvårdstjänst. För att uppfylla detta syfte formuleras och besvaras två forskningsfrågor. Den första forskningsfrågan handlar om skillnader mellan nätnografi och fokusgrupper när man ska fånga kunders behov. Den andra forskningsfrågan handlar om samskapande aktiviteter och kvaliteter för kundvärde som är nödvändiga i en digital sjukvårdstjänst för att tillgodose kundernas behov. Mer specifikt är det formulerat som ’vilka samskapande aktiviteter och kvalitetsegenskaper tillfredsställer kundernas behov i en digital sjukvårdstjänst?’ Resultat från tre artiklar och empiriska data från enkäter, nätnografi och fokusgruppsprojekt används för att belysa kundbehov.

De kontextuella skillnaderna mellan nätnografi och fokusgrupper är relaterade till de inbäddade reglerna, normerna och rum-tidsförhållanden där tjänsten utövas. Sådana förhållanden reglerar informationen om tjänsten och kundernas behov. Nätnografimetoden fångar sociohistorisk information om mer kritiska händelser, realistiska och negativa servicemöten. Angående kundernas behov så fångar nätnografimetoden mer dominerande, ouppfyllda och faktiska (verkliga) behov. Fokusgruppsmetoden är mer inriktad på information om mer positiva, minnesvärda och vanliga servicemöten. När man fångar kunders behov – genererar fokusgruppsmetoden mer jämnt fördelade, uppfyllda (tillfredsställda) och minnesvärda behov. Båda metoderna fångar i stort sett samma behov men fördelningen ser olika ut, där nätnografi är mer koncentrerad kring ett fåtal behov och fokusgruppen har mer jämnfördelning mellan de olika behoven. Nätnografimetoden fångade inte behoven av "systemkapacitet" och "åtkomst". Fokusgruppsmetodiken fångade inte behovet av företagens "ansvar".

En konceptuell modell föreslås som illustrerar fyra värdeskapande aktiviteter och kvaliteter som är nödvändiga för att kundfördelar ska växa fram. Den konceptuella modellen är en kombination av kundresa, tjänstekvalitet och värdekonceptet och ger en integrerad syn på kundernas uppfattningar om digital sjukvård. Vidare ger modellen en övergripande förståelse för vad som gör så kallade serviceresor stödjande, och hur tjänsteföretag kan optimera kundupplevelsen – i det här fallet inkluderas personlig hälsa och välbefinnande. Licentiatavhandlingen ger bidrar med slutsatser som kan användas i teori och praktik. I stora drag handlar det om medvetenhet om vikten av de regler, normer och rumtidsförhållanden som ger information om tjänsten och kundernas behov. Den konceptuella modellen kan vägleda chefer hur de kan utforma tjänstemöten med bättre kvalitet.

There is a growing interest in the use of digital technologies to create new roles and relations between health professionals and patients. This technology-enabled transformation extends the traditional interactional way to deliver healthcare services, which has been historically grounded for over 100 years. A compelling argument for this interest is that for many diseases, not least for chronically ill persons for whom the majority of practices related to treating their medical condition is carried out in their home, there is a space for healthcare service delivery that is largely invisible for the healthcare provider. Swedish healthcare is currently finding ways to adopt and utilize self-monitoring as an integral part of healthcare services. Even though there is consensus among many stakeholders that self-monitoring can be a potentially transformative force, the speed of transition is slow. The evolving phase of the healthcare service ecosystem becomes interesting to investigate and how a variety of institutional logics shape the future of the digitally engaged patient. A service ecosystem has previously been defined as “a relatively self-contained, self-adjusting system of resource-integrating actors connected by shared institutional arrangements and mutual value creation through service exchange” (Vargo and Lusch, 2016, p.10). By applying institutional theory to the case of self-monitoring in Sweden, we are responding to the call in service science to contribute to a better understanding of the service ecosystem of healthcare and what facilitates and constrains the changing roles of its actors in value creation. The purpose of this study is therefore to better understand the shift from the view of patients as passive receivers of care into being active co-producers that takes part in decision-making and in the care delivery through self-monitoring. Taking an institutional logic approach, the authors identify key “roles” (subjects), “materials” (objects) and “practices” (ways of acting) in the healthcare service ecosystem that facilitate and constrain the emergence of self-monitoring technologies. To do so, the study draws on multiple sources of evidence. First, 20 interviews have been conducted with respondents representing various key actors in the healthcare service ecosystem (e.g., health-care professionals, patient organizations, hospital managers, policy officials, pharma industries and information officers). Second, we observed a development project where new self-monitoring systems were piloted in cancer care. Our study offers several important implications for service theory and management. For service theory, this study shows how alignment and misalignment between practices, roles and materials facilitate and constrain the emergence of self-monitoring technologies within the health service ecosystem. For service management, this study raises four barriers – conflicts, compliance, lack of knowledge and appropriate technologies - that are crucial to overcome when implementing self-monitoring technologies