Abstract
A 10-year quality journey of a Swedish university hospital is described in this case study based on a variety of data sources. A series of quality initiatives were implemented according to total quality management (TQM) "best practice." Many projects were successful, but still a majority of those did not meet the staff's requirement of practical relevance, and they provoked scepticism toward instruments introduced and resistance to service-related quality definitions. The hospital's incentive structures did not reward an engagement in improvement activities. The findings are interpreted as demonstrating that the programs were viewed upon as part of a "management" rather than "professional" agenda, despite the underlying philosophy of TQM. It is suggested that applying professional practice development approaches to improvement initiatives might help to overcome the barrier thus created.