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BACKGROUND: The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. METHODS: A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. RESULTS: The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals' relative influence on group discussions. CONCLUSIONS: The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.

Purpose – The purpose of this paper is to explore what options the adult learner has for continued learning and what role universities are playing in providing net-based education. Current options for lifelong learning and improvement opportunities in the educational process are described based on an assessment inspired by principles of lean management. Design/methodology/approach – Sweden is chosen as an example. The current level of net-based university education and the demand for it is assessed using official Swedish data. Lean management principles are used as a starting point to define parameters for interest for the adult learner. These parameters are then converted into a five-level scale for assessing current performance with focus on university courses. The authors also study how Swedish County Councils manage their employee education and carry out a check of courses offered by massive open online course providers. Findings – Lean management principles in combination with customer focus seem to present relevant parameters for assessing distance education. Preliminary results indicate that lean lifelong learning has a considerable improvement potential. The main reasons for this potential seem to be more of a bureaucratic and political nature, whereas technology and resources appear to be less of an issue. Practical implications – The results have implications for both universities and organisations. The pressure on universities to become more customer-focussed, while at the same time, cost-effectiveness is likely to increase. Originality/value – Using the customer perspective for educational services and applying lean principles to education.

This article investigates the role of locally based research and development units (R&Ds) focusing on health and social services. Nearly 300 local RDs are funded by the Swedish government with the intention to facilitate knowledge transfer and development of high quality and effective health and social care organisations. Based on analyses of archival data on aims, activities and outputs of R&Ds focusing on care for older people the authors argue that local R&Ds have potentials to act as knowledge brokers, change agents and researchers, but these overlapping roles need clarified strategies and enactment of a variety of skills.

Purpose
The purpose of this paper is to identify and explore important quality-related challenges facing organizations, and investigate how current excellence models incorporate these challenges.


Design/methodology/approach
The paper is based on a Delphi study of Swedish organizations. Forty-nine challenges were generated and ranked according to importance and the ten top-ranked challenges were compared to the principles of four excellence models.


Findings
The excellence models still seem to be relevant since their content matches many of the identified challenges. The Malcolm Baldrige National Quality Award and the Swedish Institute for Quality models were found to have the most comprehensive coverage, while the International Organization for Standardization model had limited coverage.


Research limitations/implications
Three areas for further research were identified: first, how quality management (QM) can evolve in different contexts that have varying needs in terms of adaptive and explorative capabilities; second, the interfaces of QM and sustainability, and ways to understand how customers and stakeholders can be active contributors to improvements; and third, the roles of the owners and board of directors regarding QM, and how to organize and distribute responsibilities of the QM work.


Practical implications
There are three important challenges that future revisions of excellence models could address: first, making QM a strategic issue for company owners; second, involving customers in the improvement activities; and third, developing processes that are robust yet still easily adaptable.


Originality/value
The Delphi study identified upcoming challenges in the QM area based on input from 188 quality professionals.