Sweden is renowned for its excellent health system which is seen as a world-leader with high levels of equity and good outcomes. In this blog I will focus on one very well known health system in Sweden - Jönköping. Jönköping is recognised internationally as a system that has performed very well both financially and in terms of health outcomes through embedding a quality improvement (QI) and microsystem approach over many years.
In November I was lucky to be hosted by the Jönköping improvement team - Qulturum - to learn more about how they've achieved such fantastic results. Thank you to Pernilla, Egle and everyone there who made me so welcome. In this blog I’ll share three key lessons that can be applied in the NHS from their story.
1. Obsessively patient-centred
Jönköping’s focus on patients is epitomised in one word – Esther. In the late 1990s Jönköping was experiencing a crisis around beds and funding. Esther was the name of the mother of one of Jönköping’s leaders at the time and came to symbolise what was wrong with the system but also the key to how it could be improved.
Esther was 88, had heart failure, and during one particular acute episode encountered 32 different health professionals as she attempted to get support for her condition, frequently repeating her symptoms and details. No wonder it was noted in her medical records she was confused!
What emerged from this initial case study was a deep focus on Esthers across the system – reflecting on these fragmented patient journeys and how they should be made better.
The principle is that money can be saved if we just focus on doing the right thing for Esther.
The transformation seen has been dramatic. The figures below are for Höglandshospital, one of three hospitals in Jönköping, and show a dramatic reduction in both acute beds but also the number of patients living in care homes.
Transformations seen in Höglandshospital. Source: Nicoline Vackerberg
So what’s new about focusing on the patient you may ask? From my time there and discussing Esther with Nicoline Vakerberg, the passionate lead for the Esther programme, the key difference is how pervasive this focus and recognition of Esther is.
For example, improvement project teams now aim to have 25% of their members as Esthers or patient representatives. A huge amount of effort is put into coaching these representatives so they are able to actively contribute. Talking to one patient who has now become employed by Qulturum to develop patient involvement, originally some patients felt intimidated and ignored in groups. Jönköping has made sure to rectify this so involvement isn’t tokenistic but truly a partnership. Practically every conversation I had in Jönköping included reference to considering “what is best for Esther”.
This focus on Esther has led to a huge range of schemes:
- Esther cafes where patients discuss and contribute to improvement work (see below)
- Esther coaches – a scheme where staff across the organisation are trained in listening for the voice of Esther and embedding it in improvement work
- Esther home teams – who help settle patients at home after hospital admissions to reduce their chance of readmission
- Esther sim-lab – where a patient representative presents an example ilnesss with an MDT to redesign how the patient experiences care
Extract from Esther cafe leaflet
The principle of Esther has now been adopted across the world – for example in Kent and across Singapore. It also recently won an award from the European Commisssion as the best programme supporting active and healthy ageing.
For more detail on the Esther programme this Commonwealth Fund article is well worth a read.
2. Quality Improvement for everyone!
At the heart of Jönköping’s improvement efforts is Qulturum. Qulturum combines meanings: QUL is Swedish for Quality Development Leadership; Qultur emphasises the importance of culture; and Um means meeting place. Qulturum is therefore a combination of an approach to developing QI, a catalyst for cultural transformation across the region, and a building that hosts training and conferences.
Standing outside Qulturum
What differs from other quality improvement approaches I’ve seen is the scale and sustained training of staff in QI approaches. Jönköping, inspired by the IHI, use the model for improvement and plan-study-do-act (PDSA) as standard. They have spread this across the organisation for more than 20 years.
IHI’s model for improvement
Improvement is an ingrained element of everyone’s role summed up in the understanding that everyone has two responsibilities: to do what you do (be it a physio, nurse or administrator) and to improve what you do through using QI. Training takes place through a variety of routes: coaches are trained in QI and alongside their substantive clinical role are responsible for working with colleagues to deliver improvement projects.
Medical training has adopted QI and includes a number of modules for doctors so they are equipped not just in clinical skills but also in improving ways of working by the time they graduate.
The philosophy underpinning this large-scale training of the workforce in QI is summarised by Sven Olof Karlsson, Jönköping’s previous CEO, in Baker et al’s excellent High Performing Health Systems (2008)
3. In it for the long run
Whilst the focus on Esther and the up-skilling of staff are central to Jnkoping’s success, they have been enabled by continuity amongst the top-team of the county. Indeed, one interviewee cited by Baker et al (2008) stated “political stability and leadership continuity are the single most important factors in Jonkoping’s success”.
The journey to introducing these principles was started around 1997 by chief executive Sven Olof Karlsson who remained in role until his retirement in 2008. Mats Bojestig, Chief Medical Officer for the region, and Goran Henriks, Chief Executive of Learning and Innovation at Qulturum, led the change from the outset and remain in post today over 20 years later.
This continuity of leadership has been a key enabler for this work to remain focussed and unwavering in its principles. Similarly, the Esther project started in 1997 and still remains a core element of the system under the same leadership. This consistency of purpose and leadership is remarkable and has ensured that, whilst evolving, the same principles of patient-focus and up-skilling all staff have remained central to Jönköping’s approach.
Jönköping’s story is inspirational and has some clear lessons that can be applied in the NHS and indeed have been in a number of systems. I learnt about Jönköping after some colleagues recommended I attend their annual Microsystem conference which showcases innovations from Jönköping and across the world. It was a fantastic experience and if you’re interested in QI or Microsystems I strongly recommend you go - you can sign up here.