Chapter 4: Jönköping County Council - Småland, Sweden

Citation Information Baker, G.R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. "Jönköping County Council." High Performing Healthcare Systems: Delivering Quality by Design. 121-144. Toronto: Longwoods Publishing. • Order the printed paperback version.

Highlights of recent achievements "Jönköping County opens the minds of their peers and offers hope, encouragement, and new ideas. Their superb teamwork and organization have helped us all to think more clearly and to act more boldly." - Donald Berwick (quoted in Institute for Healthcare Improvement nd a) For the past decade Jönköping County Council - a county council in southern Sweden serving a population of less than 340,000 - has gained national and international recognition for making and sustaining large-scale improvements in healthcare. For many international leaders in the field of quality improvement, Jönköping exemplifies the innovation, strong and stable performance and social values on which Swedish healthcare was founded, and provides a model of healthcare system transformation that ranks among the best in the world. While Jönköping was a well-kept secret for some time, it has become a popular site to visit for healthcare leaders eager to learn more. Figure 1 shows that compared to the other 20 county councils in Sweden, Jönköping achieves the best overall ranking on indicators across Sweden's six goals for quality: efficiency, timeliness, safety, patient centredness, equity and effectiveness (Jönköping County Council 2005). [Figure 1] Jönköping has dramatically reduced its rates of sepsis and made impressive measurable gains in chronic disease management while reducing staff absenteeism and turnover. The council estimates that its work on efficiencies has led to 80 million SKr savings ($13.5M CAN), or 2% of its net costs (Jönköping County Council 2005). Jönköping has won national recognition by the Swedish quality award for healthcare - Qvalitet, Utveckling, Ledarskap (QUL) - on multiple occasions over the last decade. This award is often referred to as the Swedish Malcolm Baldrige award. Two initiatives stand out among Jönköping County Council's achievements: Esther Esther is a persona that clinicians in Jönköping invented to help them improve patient flow and coordination for seniors in six of the county's municipalities. Care for the elderly is a critical issue in Sweden, a country that has the world's oldest population (18% are aged 65 or over). Esther is an 88-year-old Swedish woman who continues to live alone in the community but has a chronic condition and occasional acute needs. Beginning in late 1998 Jönköping clinicians and leaders came together to map Esther's movements through the complex network of care settings and providers. In addition, interviews were conducted with patients like Esther and clinicians who provide care for her across the system. This exercise provided a starting point for identifying and working on improvements in the way patients flow through the care system. Much work was done to align capacity with demand and to strength coordination and communication among providers. Examples of changes made included a redesigned intake and transfer process across the continuum of care, open access scheduling, team-based telephone consultation, integrated documentation and communication processes and an explicit strategy to educate patients in self-management skills. The Esther project yielded impressive improvements over a three- to five-year period, including an overall reduction in hospital admissions by over 20% (9,300 to 7,300) and a redeployment of resources to the community, a reduction in hospital days for heart failure by 30% (from 3,500 days per year to 2,500) and a reduction by more than 30 days of wait times for referral appointments with specialists such as neurologists (Institute for Healthcare Improvement nd b). Pursuing Perfection Pursuing Perfection was an ambitious project funded by the Robert Wood Johnson Foundation and directed by the Institute for Healthcare Improvement (IHI) in the United States (US). The goal was to create system transformation across all major healthcare processes. Seven successful US health system applicants received over $2 million each through a competitive process to participate in this initiative. Jönköping (and several other international health systems) participated without this funding. Jönköping County Council leaders considered their Pursuing Perfection efforts to be an investment that built on the Esther initiative and helped to transform the way care is provided. Top managers wondered whether it would be possible to develop "a Toyota in healthcare." Their efforts focused on developing new ways of working and tools at three levels: leadership, new designs and innovations, and front-line results. Jönköping leaders and clinicians focused their efforts on systems thinking at all levels (i.e., macro, meso and micro) in several areas, including achieving access in every office, improving patient flow, asthma care, elder care, partnerships for children's services in the county, prevention of influenza and patient safety. This work led to substantial streamlining of processes and cost savings across the system, including in surgical units and orthopaedic clinics. Key changes included role redesign with occupational therapists and nurse practitioners having more enhanced roles in doing follow-up exams. By bringing together all providers and resources for children with asthma in the county and by mapping and improving processes, Jönköping reduced the number of hospitalizations for pediatric asthma to 7 per 10,000 (Jönköping formerly had 22 hospitalizations per 10,000; the US national average is 30 hospitalizations per 10,000). Jönköping's rate of influenza vaccination increased by 30% (over four years), translating into substantial reductions in acute care hospital admission as well as in morbidity and mortality among the elderly population. Jönköping County was considered the highest performing of all Pursuing Perfection sites, financially and clinically, thereby demonstrating "that gains are possible when innovative design meets rational resourcing" (Institute for Healthcare Improvement nd a). Setting an example It is uncommon to be publicly praised and held up as an example to peers in Sweden, where unity, modesty and equality are strongly valued. That is no longer the case for Jönköping County Council. In a report published by Sweden's Department of Finance in 2005, Jane Cederqvist urged other county councils to build on Jönköping's successes in transforming its system and noted the resulting possibility of realizing cost savings across the country: We have done some calculations, and our evaluation of the counties in Sweden shows that it is possible to save at least 30,000 million SKr [$5 billion Canadian] in a 10 year period. ... It would be very good for Swedish health care if we can start a Pursuing Perfection project in Sweden based on the successes the County Council of Jönköping have achieved in their care. This should develop all of Swedish healthcare a lot, and offer us new learning and the inspiration needed for tomorrow's work in healthcare. (Jane Cederqvist; qtd. in Berwick 2006: 54) These results are impressive. But beyond what is published in facts and figures - comparative county-level performance rankings, awards, key improvement initiatives and results - little is known about how Jönköping developed into a system capable of improvement. For the full case please go to: Chapter 4: Jönköping County Council - Småland, Sweden For commentary on this case by Maura Davies please to to: Commentary: Jönköping County Council