Charting the Way to Greater Success: Pursuing Perfection in Sweden

​In Jönköping County, Sweden, Pursuing Perfection is making a strong county-wide health care system even stronger.
The Challenge
In the 1980s and 1990s Sweden’s Jönköping County steadily improved its health care services. Its professionals were proud of their progress, and, in fact, they won national recognition for their achievements.
But at the same time they were unsure of how to build on their success. They lacked a clear understanding of what had been most effective in creating it. They needed a conceptual framework to guide future initiatives.
And they had plenty of initiatives that needed guiding. Among other things, they wanted to free up health care providers to see patients in a more timely fashion. They wanted to improve efficiency in moving patients through their acute care facilities, especially their surgical units. And, with health care costs rising, they wanted to realize savings in both time and money.
Sweden’s Health Care System and Jönköping County
Health care in Sweden is the responsibility of the public sector. At the national level, the Ministry of Health and Social Affairs establishes objectives for quality, equity, and efficiency. At the regional level, political units called “county councils” implement those guidelines and secure the quality of care for their residents.
A typical county health system includes primary care clinics, specialized medical services, rehabilitation facilities, and pharmacies. Each council actually owns and runs its health facilities and appoints a management team headed by a chief operating officer.
Over the last 20 years, Sven-Olof Karlsson has led the management team for Jönköping County. To spur improvement Karlsson established the Medical Services Discussion Group, a forum for the county’s 80 management personnel and operational managers. He organized the discussion group through one of the county’s unique institutions, Qulturum. A combination of think tank and conference center, Qulturum supplied the county’s discussion group with professional facilitators and theorist-scholars who specialize in health care.
 Sven-Olof Karlsson, CEO, leads a management team 
discussion group at Jönköping County Council
Cultural Lessons from Esther
Before joining Pursuing Perfection, Jönköping County had begun The Esther Project, a program to improve the delivery of health care services to its elderly population. As its name implies, Esther’s staff was determined to put a human — and humane — face on their efforts.
And Esther did make striking gains. Among its accomplishments: a reduction in hospital admissions; a 30 percent decrease in hospital days for heart failure; a reduction in waiting time for referral appointments with neurologists from 85 days to 14 days; and a decrease in the waiting time for referral appointments with gastroenterologists from 48 days to 14 days.
Impressive results. But according to Göran Henriks, Jönköping Director of Development and co-project leader for Pursuing Perfection, the most valuable results of The Esther Project were its “cultural lessons”:
  • Concentrate on what patients value, not on what professionals value.
  • Involve all suppliers and caregivers in prioritizing those patient values.
  • Understand that each step in a process is dependent for its success on the steps that precede and follow it.
“Follow these guidelines,” Henriks says, “and everyone wins.”
Pursuing Perfection Arrives
Jönköping County began its association with Pursuing Perfection in 2001. The cultural lessons of The Esther Project, in conjunction with the new processes and concepts from Pursuing Perfection, led to advances across the county’s health care system.
Surgical Units
Traditionally, the scheduling of procedures in the surgical units of Jönköping County’s three hospitals was based not on demand but on arbitrary factors, few of which took into consideration the well-being of patients.
Managers of the three surgical units, guided by the principles of Pursuing Perfection, adopted a standardized set of tools for measuring flow, access, and the lead time required for efficient scheduling. Beginning in September 2004, the three hospitals’ managers took regular measurements every four months. Comparing those measurements enabled them to identify differences among the three units and pinpoint the causes of those differences.
“This gave us transparency in planning our scheduling, so now there is very little variation between the three hospitals,” Henriks says. “For example, we can schedule anesthesia nurses in a way that more accurately and economically meets demand. Our improvement in scheduling means we are clearing bottlenecks and reducing waits.”
Another useful discovery was that any delay at the beginning of the work day propagates throughout the day, and as time goes on, the delay grows longer and more disruptive. The discovery led each operating room to establish a consistent daily starting time and impose on itself the discipline of adhering to that time.
Orthopedic Clinic
By 2003, the wait for appointments with specialists at the Jönköping County Orthopedic Clinic was growing longer and longer. More and more patients were seeking care for complaints associated with the misuse of computer keyboards.
Clinic professionals used Pursuing Perfection to map their existing processes and design a new, streamlined approach. The mapping helped them identify and eliminate redundancies, unnecessary complexity, and inefficiencies.
An increased role for occupational therapists was key to the new, streamlined process. Therapists, instead of physicians, did screenings and follow-up exams. The result: Physicians were immediately freed to see other patients, and in 2003 alone, the clinic saved approximately 750,000 SEK (around $100,000 USD).
“Today,” says Mari Bergeling-Thorell, Occupational Therapist and Project Leader, “the annual savings are even greater, and we’re discussing whether or not occupational therapists can take over certain doctor visits for patients suffering from knee trauma without bleeding.”
Pursuing Perfection encouraged Jönköping County to apply the lessons learned from the streamlining of its orthopedic clinic to other patient processes. Now, when a patient visits a primary care clinic for a common infection such as a cold, the patient first sees a nurse practitioner. Under the supervision of the primary care physician, the nurse practitioner has the authority to make a diagnosis and initiate treatment. If medication is needed, the nurse will, of course, consult with the physician, and, if medication is called for, the physician will write a prescription. If further investigation is required, the nurse will hand over care to the primary care physician.
The Qulturum in-house think tank and conference center, Jönköping
The Children’s Dialogue Project
The primary goal of the county’s Children’s Dialogue project is to facilitate cooperation among all health care providers working with children.
“Pursing Perfection gave Children’s Dialogue a strong boost,” says Boel Andersson Gäre, Chief Physician and Manager of The Children’s Health Services. “It helped us define our methods. Although each member of our staff was responsible for just a part of the entire project, through Pursuing Perfection everyone came to share the same vision and work toward the same goal. Today, for example, communications are much better between our hospitals’ neonatal wards and our family centers.
“Pursuing Perfection has also given us the tools to help measure our progress and even to evaluate evidence that contradicts expectations. For example, we have been quite successful in decreasing the number of asthmatic children who visit our acute care facilities. The numbers are currently down to five children per thousand.”
Opening the Way to Innovation
With the help of Pursuing Perfection, the health care professionals of Jönköping County have achieved an unusual command of their system. But that understanding is only the means to a greater end. The ultimate goal is innovation that improves the quality of people’s lives.
For example, the Children’s Dialogue project is now able to identify and assemble all the resources needed to support children whose parents are severely ill. A new mentorship program is helping those children adjust to their difficult circumstances. Pursuing Perfection has proved instrumental in creating more humane care for the county’s youngest residents.
Pursuing Perfection has helped the health care professionals of Jönköping County keep the entire picture in mind at all times. No one thinks they have found a panacea, but they do value the many tools that Pursuing Perfection has given them to help improve flow, cooperation, and patient access to the system. The extent of their appreciation is apparent in the fact that they have written the essential concepts of Pursuing Perfection into the county council’s business plan.
Moreover, Jönköping County has helped Pursuing Perfection.  As the only participating health care system with fully integrated services and a single payer for all of its services, the county has demonstrated the gains that are possible when innovative design meets rational resourcing. Every organization in Pursuing Perfection has learned from Jönköping County.
Transforming health care to a new level of performance:
Leading the way, Göran Henriks, head of Qulturum, and physician Mats Bojestig,
head of Internal Medicine at the Highland Hospital in Eksjö
“Health care is a values-based system. Pursuing Perfection provides ways for articulating, agreeing on, and inculcating values that focus on the patient.”
—Göran Henriks, Jönköping Director of Development and co-project leader for Pursuing Perfection
“Jönköping is setting the pace for many of the system-level dimensions of quality that Pursuing Perfection has tackled. Because the county’s leaders are working in a different cultural, political, and financial environment from the US sites, Jönköping provides an unusual opportunity to challenge cherished assumptions and habits of the American health care system. Jönköping County’s professionals open the minds of their peers and offer 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, MD, MPP, FRCP, Former President and Chief Executive Officer, Institute for Healthcare Improvement
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