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Many countries institutionalize evaluation systems at different levels of governance to enhance quality in eldercare. In Sweden, which is the focus of this paper, the Health and Social Care Inspectorate (IVO) (www.iwo.se) is responsible for improving quality in eldercare through state supervision, and the National Board of Health and Welfare (www.socialstyrelsen.se) and the Swedish Association of Local Authorities and Regions (SALAR) run a national indicator-based benchmarking evaluation system for improving eldercare. In addition, local evaluation systems are set up to monitor and evaluate eldercare. Although evaluation systems are built to support public policy and governance in different ways (Hanberger, 2011; Hood, 1991; Pollitt and Boukaert, 2011; Kusek and Rist, 2004; Radin, 2006; Van Dooren et al, 2010), ultimately they are aimed to improve quality of care but the ways to achieve this differ.

Researchers are concerned about the growing accountability pressure that professionals are subjected to (Ubels, 2015), and if external supervision is doing more harm than good (Beddoe, 2012; Furness, 2009). Disputes concern the value of hard evaluation systems (e.g. state supervision) and soft forms (e.g. benchmarking systems), for improving quality in eldercare, and that performance measures do not reflect care provided to concrete persons in concrete situations (Jerak-Zuiderent 2015). Braithwaite et al (2007) demonstrate that external inspection of nursing homes often fails because of “a variety of kinds of regulatory ritualism” (p.11). Inspections tend to prioritize paper-work, to fill in forms on outputs and other required information instead of 'pick important problems and fix them'.

While policy makers generally convey high expectations to external evaluation professionals convey lower expectations or even resistance. This reflects a tension between political (hierarchical) accountability (Behn, 2001), which implies that performance of social services is monitored against politically and administratively predefined standards, and professional accountability, where good performance is based on trust in the professional agent being qualified to make situated judgment and improve practice (Evans, 2011; Evetts, 2009). While evaluation for political accountability conveys an inbuilt distrust in professionals, it relies on professionals to improve the performance of services (Van Dooren et al, 2010). 

Although evaluation systems are key components in eldercare governance (Clarkson & Challis, 2006; Johansson et al, 2015; Munro, 2004; Szebehely and Trydegård 2012) they have been scarcely researched, particularly how different systems operate in practice. If and how national and local evaluation systems, one by one and together, contribute to improve quality in eldercare is here further explored.

This paper scrutinizes how two national evaluation systems and one local system operate in a Swedish municipality. National evaluation systems are the same for all communities whereas local evaluation systems vary (Lindgren, 2015). The three evaluation systems are all intended to support and maintain quality in eldercare. The focus is on the accountability and quality improvement functions, and the evaluation systems’ consequences for key-actors. A close look at one case, a Swedish municipality, allows for analyzing and comparing how the accountability and quality improvement function of three radically different evaluation system evolve and interplay at different local levels.