Improving Patient Flow: The Esther Project in Sweden

​"Esther" is not a real patient, but her persona as a gray-haired, ailing, but competent elderly Swedish woman with a chronic condition and occasional acute needs has inspired impressive improvements in how patients flow through a complex network of providers and care settings in Höglandet, Sweden.
Esther was invented by a team of physicians, nurses, and other providers who joined together to improve patient flow and coordination of care for elderly patients within a six-municipality region in Sweden. The productive work that has been done on Esther's behalf recently led the Jönköping County Council, responsible for the health care of 330,000 residents living around Höglandet, to become one of two international teams participating in the Pursuing Perfection initiative. This program, launched by The Robert Wood Johnson Foundation, is designed to help physician organizations and hospitals dramatically improve patient outcomes by pursuing perfection in all their major care processes. The Institute for Healthcare Improvement (IHI) serves as the National Program Office for this initiative.
"I think it is very important that we call this work Esther," says Mats Bojestig, MD, Chief of the Department of Medicine at Höglandet Hospital, Höglandet, Sweden, one of the developers of the Esther Project, and an IHI faculty member. "It helps us focus on the patient and her needs. We can each imagine our own 'Esther.' And we can ask ourselves in our work, 'What's best for Esther?'"
Esther proved inspirational for the team. During the three-year project, they were able to achieve the following improvements:
  • Hospital admissions fell from approximately 9,300 in 1998 to prognostic 7,300 in 2003.
  • Hospital days for heart failure patients decreased from approximately 3,500 in 1998 to 2,500 in 2000.
  • Waiting times for referral appointments with neurologists decreased from 85 days in 2000 to 14 days in 2003.
  • Waiting times for referral appointments with gastroenterologists fell from 48 days in 2000 to 14 days in 2003.
The Esther Project grew from a need that many US health systems share: to improve the way patients flow through the system of care by strengthening coordination and communication among providers.
Bojestig tells Esther's story this way: "Esther is 88 and lives alone in a small apartment. During the past few nights her breathing has become worse and worse, and her legs have edema severely enough that she cannot lie down, but sits up all night. She knows she needs health care. She phones her daughter in a nearby town, who tells her to call her home nurse. The home nurse visits and says she needs to see her general practitioner (GP). But Esther lives on the third floor and can't manage the stairs.
"So the nurse calls an ambulance, and Esther goes to the doctor, who says she needs to go to the hospital. Now three hours have passed. An ambulance takes her to the emergency room (ER), where she meets an assistant nurse and waits for three hours. She meets with a doctor, who examines her and orders an x-ray, and says she will have to be admitted. She comes to the ward and meets more nurses."
Here Bojestig smiles. "Most days Esther is a little lonely, but today she is happy because she has already met 30 people!"
The Swedish health system is designed in a traditional, functional way: Each link in the care-giving chain — the primary care physician (PCP), the hospital, the homecare providers, the pharmacy — acts independently according to its function. "But Esther needs it to all fit together," says Bojestig. "It needs to flow like an organized process," he says, so each provider of care can take advantage of what others have done or will do.
Out of this need grew the Esther Project, which has six overall objectives:
    1. Security for Esther
    2. Better working relations in the entire care chain
    3. Higher competence through the care chain
    4. Shared medical documentation
    5. Quality through the entire care chain
    6. Documentation and communication of improvements
The Esther Project team consisted of physicians, nurses, social workers, and other providers representing the Höglandet Hospital and physician practices in each of the six municipalities. They were divided into two subgroups: the strategy group and the project management group.
To establish a clear picture of where the problems existed, team members conducted more than 60 interviews with patients and providers from throughout the system. Together they analyzed the results, which included such statements as "patients in a nursing home rarely see their doctor" and "a patient getting palliative care at home was in contact with 30 different people during one week."
According to Bojestig, the interviews also furnished providers with valuable realizations about how their individual work processes did or did not dovetail with the work of their colleagues in the care chain. Figuratively, if not literally, he says, interviewers would exclaim, "Are you doing that?!? I'm doing that, too!"
The result of this lack of coordination, he says, is that while Esther's social worker knows all about how Esther lives, for example, "still her GP asks her how she lives, and she tells it, and the hospital asks her, and she tells it again, and so on." Lack of coordination of information, particularly where medications are concerned, causes considerable redundancy and waste. In the worst case, it can lead to medical errors.

The team devised an action plan that spelled out six main projects designed to correspond to the six goals.
The projects the team identified were:
    1. Develop flexible organization with patient value in focus
    2. Design more efficient and improved prescription and medication routines
    3. Create ways in which documentation and communication of information can be adapted to the next link on the care chain
    4. Develop an efficient IT-support through the whole care chain
    5. Develop and introduce a diagnosis system for community care
    6. Develop a virtual competence center for better transfer and improvement of competence through the care chain
Bojestig says that as part of its work, the team examined demand and capacity within the system, and saw that the inadequate capacity for planned care was forcing patients to seek urgent care in inappropriate settings. "If Esther complains of headaches, and her GP says she should see a neurologist, in our system that referral would take three months. For Esther this is not acceptable. So she goes to the ER, and the doctor there knows that if he puts her in the hospital, the next day there will be a neurologist in to visit her."
Although it appeared that the demand was for inpatient admissions, it was really demand for better access to specialty care. So the team tested a process in which the "queue" for care was redesigned from two — one for acute care and one for planned — into one. "Instead of having acute care go into the wards," says Bojestig, "it goes to the team."
The team, which includes the PCP, specialists as appropriate, nurses, and home nurses, has a more collaborative relationship through which they decide together what's best for each patient. When a patient presents acute care needs, says Bojestig, the PCP can page a specialist on the team, who is expected to respond within two minutes. A telephone consultation can still result in an inpatient admission, but it allows the patient to be admitted directly to the ward without having to endure a visit to the ER, costly in both human and financial terms.
For their part, the specialists began working toward open access scheduling, in which patients could be seen on the same day they call or their PCP calls. Closer cooperation among specialists and other providers meant that PCPs and homecare nurses were able to do for patients some of the things specialists had been doing.
Additionally, patient education was recognized as a critical element in keeping patients out of the hospital. Nurses were trained to educate heart patients, for example, about how to take vital measurements at home and tweak their medication accordingly.
Bojestig says that all 250 providers in the network received training in the project's goals and processes. And the investment paid off. "We have closed about 20 percent of our bed capacity," he says, "and moved that capacity to where the need is bigger."
The continuing focus of the team's work, says Bojestig, is "how to create value for Esther." He says that the project changed the attitudes among those who work for Esther, because "the focus is on her now."
"The important things for us to ask as leaders or workers in the health care system," says Bojestig, "is can we still continue to work in systems that are not integrated? Is it fair to our knowledge? Is it what we want to do? Is it best for Esther?"
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