Sustaining improvement? The 20-year Jönköping quality improvement program revisited.

Original Article

¨ oping ¨ Sustaining Improvement? The 20-Year Jonk Quality Improvement Program Revisited Anthony Staines, PhD, MBA, MHA, MPA; Johan Thor, PhD, MD, MPH; Glenn Robert, PhD Background: There is scarce evidence of organization-wide and sustained impact of quality improvement (QI) pro¨ oping ¨ grams in health care. For 20 years, the Jonk County Council’s (Sweden) ambitious program has attracted ¨ oping’s ¨ attention from practitioners and researchers alike. Methods: This is a follow-up case of a 2006 study of Jonk improvement program, triangulating data from 20 semi-structured interviews, observation and secondary analysis of internal performance data. Results: In 2010, clinical outcomes had clearly improved in 2 departments (pediatrics, intensive care), while process improvements were evident in many departments. In an overall index of the 20 Swedish ¨ oping ¨ county councils’ performance, Jonk had improved its ranking since 2006 to lead in 2010. Five key issues shaped ¨ oping’s ¨ Jonk improvement program since 2006: a rigorously managed succession of chief executive officer; adept management of a changing external context; clear strategic direction relating to integration; a broadened conceptualization of “quality” (incorporating clinical effectiveness, patient safety, and patient experience); and continuing investment in QI education and research.Physician involvement in formal QI initiatives had increased since 2006 but remained a challenge in 2010. A new clinical information system was being deployed but had not yet met expectations. Conclusions: This study suggests that ambitious approaches can carry health care organizations beyond the sustainability threshold. Key words: case study, CEO succession, culture, health services management, leadership, outcome and process assessment (health care), patient safety, quality improvement, sustainability, total quality management

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here is enduring uncertainty about the effectiveness of different health care improvement program designs, especially throughout larger organizations or systems.1 While there is a rich literature outlining quality improvement (QI) interventions,2–9 the evidence of the long-term impact of such approaches remains limited. This is due, in part, to the limited amount of research undertaken to generate such evidence, and also to a dearth of health systems with

´ eration ´ Author Affiliations: University Lyon III, France and Fed des ˆ hopitaux vaudois, Prilly, Switzerland (Dr Staines); Medical Management ¨ oping ¨ Centre, Karolinska Institutet, Stockholm, and The Jonk Academy for ¨ oping ¨ Improvement of Health and Welfare, Jonk University, Sweden (Dr Thor); and National Nursing Research Unit, King’s College, London, United Kingdom (Pr. Robert). Correspondence: Anthony Staines, PhD, MBA, MHA, MPA, Rue du Village 24, 1127 Clarmont, Switzerland ([email protected]). ¨ oping ¨ At the time of the study, J.T. was director of the Jonk Academy for ¨ oping ¨ Improvement of Health and Welfare at Jonk University. The ¨ oping ¨ Academy is funded in part by the Jonk County Council, along with ¨ oping ¨ ¨ oping ¨ Jonk University and the municipalities in Jonk County. A.S. and G.R. have no competing interests. ¨ oping ¨ The study was commissioned, and partly funded, by the Jonk ¨ oping ¨ Academy for Improvement of Health and Welfare, Jonk University, Sweden. A.S. designed the research and carried out data collection and the first draft of manuscript. J.T. provided data and advice on local context and cultural aspects. A.S., J.T., G.R. were involved in data interpretation, case analysis, and developing and finalizing the manuscript. All authors read and approved the final manuscript. Q Manage Health Care Vol. 24, No. 1, pp. 21–37 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright

DOI: 10.1097/QMH.0000000000000048 January–March 2015 r Volume 24 r Number 1

a longer track record of systematic, and system-wide, improvement efforts. ¨ oping ¨ A previous study of the Jonk QI program, having identified it as one of the leading examples worldwide, suggested that there may be an investment threshold when establishing an improvement program.10 Before passing this threshold, systems may invest in improvement capacity without necessarily exhibiting system-level improvements in performance. Other research suggests that success when establishing improvement practices in a health care organization will depend on the fit between the approach taken and the needs, circumstances, and ambitions of the organization.11 Furthermore, an organization’s ability to measure and demonstrate the impact of improvement efforts on performance is essential. Without it, the ongoing investment of time and resources into an improvement program will be hard to justify and maintain. By revisiting this successful “extreme case,”12 this study seeks to expand the evidence base for QI program effectiveness and sustainability, building on these previous findings. Much has been said and written about the ambitious ¨ oping. ¨ and highly visible improvement program in Jonk How much of this commentary is supported by evidence of performance improvement? And if improvement is evident, how has it been accomplished? These questions are of interest to the scientific community ¨ oping ¨ and have led researchers to include Jonk County Council (JCC) in several case studies.10,13-16 Has the system sustained its QI program and surpassed the investment threshold? Can a clearer signal of performance improvement due to its QI program be detected? If so, how did it achieve this? What general www.qmhcjournal.com

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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lessons can be drawn from the 20-year story of the ¨ oping ¨ Jonk QI program that can enhance the design and utility of QI programs elsewhere?

STUDY SETTING, DESIGN, AND METHODOLOGY ¨ oping ¨ Jonk County Council, 1 of 20 democratically governed councils in Sweden, is responsible for providing health care services for its 340 000 inhabitants. More than 90% of its resources are dedicated to that purpose. The County Council also runs public transport services and promotes cultural activities as well as regional development. In the 1980s, some health care departments started various QI activities and, in the early 1990s, the JCC launched an institutional QI program, developing it incrementally and never discontinuing it. It also partnered with the US-based Institute for Healthcare Improvement (IHI), which gave the program international attention and led to the exchange of ideas and experiences. Qulturum, established in 1985, supports improvement and learning system-wide, and houses a conference and training center for the JCC. The JCC story is best understood within the national Swedish health care context and its evolution between 2006 and 2010. A national program for annual “Open Comparisons” of clinical performance indicators was launched in 2006,17 leading to a greater focus on outcomes and comparative performance in Swedish health care (and other public services). In 2010, there was (still) strong political emphasis nationally on improving access by reducing waiting times. Furthermore, a new law on patient safety was issued, requiring all health care providers to undertake systematic patient safety work—including root cause analyses for very serious adverse events—and to issue a yearly, publicly available patient safety report. Study design and data

This case study uses the same design and methodology as the initial case study of the same organization, carried out in 2006, and described previously18 as part of comparative research on 3 leading QI programs.19 The case study methodology can yield in-depth understanding of events in a particular context over time,20 particularly, here, of how improvement is approached; why, in a complex system, some interventions are successful and others not21 and how each stakeholder group is involved and impacted.22 Data gathering was carried out (by the first author, in English) on site in August 2010, through semistructured interviews, observation, and collection of written material (see Figure 1), with supplementary data provided subsequently by some interviewees via e-mail. A sampling frame was defined for the 2006 case study, to cover a variety of departments and hierarchical levels, including internal informants and a small number of external stakeholders. The design also allowed inclusion of an extended, opportunistic, set of interviews,

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adding to the predefined set. That frame was retained for this follow-up study. The interview strategy was based on Øvretveit’s recommendation,23 “The researcher gathers data about the effects of the program by interviewing health personnel to find out what difference the program made for them and their views about the effects for patients (what would have happened without the program?)” To be able to triangulate data, Øvretveit suggests: “One technique is to ask informants if they know of any evidence which would prove or disprove their perceptions. In addition, the researcher asks informants for their ideas about which factors helped and hindered the intervention—their theories of causality— and for evidence which might support or disprove their ideas.” The 2010 update included 20 interviews (40 in 2006). Ten of the people interviewed in 2010 had been interviewed also in 2006; the other 10 were new interviewees. In the first category, interviews concentrated on the evolution of the QI program since 2006, including a number of follow-up questions on the issues that had emerged as the major challenges in 2006. With the second category, interviews focused on exploring current issues, challenges, strengths, weaknesses, and results. The data set that was built for the 2006 study was extended. All interviews were transcribed. Quotations from interviews have been transcribed literally, using the words chosen by the interviewees; only grammatical edits have been made as English is not the native language of the informants. In addition, the research included 10 hours of observation, covering: visible artifacts of culture, architectural layout, the JCC Intranet, QI projects, and results displayed in the departments; project planning at Qulturum; informal conversations at the hospital cafeteria; meetings; and training sessions. Observations were documented in voice recordings and transcribed before data analysis. The scope of data collection in 2010 was the same as that of the 2006 case study: it investigated the Improvement Program within JCC’s corporate management organization, as well as within 1 of its 3 hospitals: the ¨ oping, ¨ Ryhov hospital, located in the town of Jonk chosen because it is the largest and the referral hospital for the county. The data were reviewed and synthesized to form the case description. FINDINGS To address the research questions regarding a QI program’s effectiveness and sustainability, we first report on indications of performance improvement in the case organization. Next, we revisit the 3 challenges for its QI program identified in the 2006 study. Then, we examine subsequent program challenges and developments and how each played out in the JCC during the period 2006-2010 including CEO (chief executive officer) succession, changes in the external context, and an explicit commitment to patient safety.



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Figure 1. Strategy for data collection and analysis.

Performance

In 2006, we noted evidence of process improvement in a number of departments and improved clinical outcomes in pediatrics. We also found that considerable work had been done on access, with great success in some departments and none in others. By 2010, access had improved in most of the departments, at least in absolute terms, since 2006, although in relative terms it had not, as other County Councils had improved faster since that time. While there was little competition on access in 2006, there was rather fierce competition in 2010 (spurred on by na¨ oping ¨ tional policy initiatives). By then, Jonk was, however, still among the best of the 20 county councils on access. Most of the improvement occurred in the previous 2 years with the introduction of financial incentives having played an unquestionable role in that improvement. The annual national Open Comparisons stimulated work on outcomes improvement. By 2010, the JCC had climbed up the rankings since 2006. Researchers had developed an index24 aggregating performance scores on each indicator to yield a global ranking of County Councils; a similar type of index had already been compiled internally by JCC in 2006. According to these 2

indices, JCC was never below third position in the ranking of the 20 County Councils for years 2005-2009. In 2010, the index based on the national open comparison (for 2009) had the JCC at the first rank. While still among the best on access, the JCC was no longer on top of the list for that item. Patient satisfaction had remained very good and stable and so had the financial indicators. But on the open comparison’s clinical indi¨ oping ¨ cators, Jonk had definitely improved. The index used for comparison consists of 18 indicators, out of which JCC was in the top 3 in preventive work, patient trust, women’s health, orthopedics, psychiatry, surgical care, and “other treatments” (see Figure 2). In 2010, the index based on the national open comparison (for 2009) had the JCC at the first rank. The financial situation of the JCC was good in 2006 and remained so in 2010; the JCC had managed to remain financially sound over time. There was a shared understanding that the County Council had to have a surplus each year for future investments and that, if there was a financial crisis, there should not be abrupt measures, but incremental changes allowing it to sustain continuity and motivation. The JCC had managed to retain this surplus almost every year, except for 1 year in the early 2000s and perhaps 1 year in the 1990s.


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partment was no longer “top of Sweden” in areas where it had been so in 2006. For example, the rate ¨ oping ¨ of admissions for acute asthma, that Jonk had been a leader in decreasing up to 2006, continued to decrease by 2010, but, while still below the national ¨ oping ¨ average, Jonk was no longer at the top of the national ranking. By 2010, the proportion of newborns who were breastfed remained stable. Outcomes were in the middle of the range in diabetes. The partnership with patients and relatives had been developed. In 2010, the department had 20 groups working on various improvement initiatives and 100 out of its 180 professionals participated in at least one of these groups and about 140 were involved in some part of the improvement work.

Figure 2. Open comparison—overall index 2009.

We are now going to report on 2 departments where clinical outcomes had improved (pediatrics and intensive care unit [ICU]) in the period 2006-2010, then what had happened in other units and then end with hospitalwide performance considerations. Pediatrics The department of Pediatrics won the 2009 Swedish Quality Award (see: www.siq.se), based on the Baldrige framework (http://www.nist.gov/baldrige/), not specific to health care. The award is based on comprehensive self-assessment of an organization’s improvement program and its performance and is awarded on the basis of review and site visits by independent experts. The award indicates that the organization is considered a role model for other organizations and suggests a comprehensive approach to QI in this particular department. Compared with 2006, there were more metrics in which improvement was evident in 2010, but the de-

Intensive care In intensive care, our fieldwork confirmed that there had been a tremendous decrease in catheter-related bloodstream infections. There were none for 18 consecutive months (2009-2010). For ventilator-associated pneumonias, there was only a slight decrease, because the number of cases remained the same but the number of ventilator days increased (see Table 1). The ventilator-associated pneumonia bundle25 was in place, but there was no systematic adherence measurement. After implementing a local version of the “surviving sepsis” campaign,26 the sepsis mortality rate had been almost halved. Clinicians in the ICU followed new research findings closely, and care bundles were adapted to incorporate new knowledge (Figure 3). Other units Departments other than pediatrics and intensive care also had QI projects and data to share. Most of these examples were about improving processes, with impacts on waiting times, patient satisfaction, and staff satisfaction, as in 2006. Evidence on improved clinical outcomes, however, remained scarce. Results of improvement work, including clinical improvement, were posted on billboards in many units. All departments

¨ oping ¨ Table 1. VAP and CRI for Jonk Ryhov ICU

Ventilator-associated pneumonia (n)

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

3

5

5

4

5

6

4

2

5

3

Number of mechanical ventilations (MV)

83

97

121

114

131

137

139

142

Ventilator hours

17 039

17 646

22 701

22 670

25 472

29 229

28 519

36 863

Ventilator days

710.0

735.3

945.9

944.6

1061.3

1217.9

1188.3

1536.0

6.0

4.1

4.1

5.3

3.1

1.5

3.6

2.1

7.0

5.4

5.3

6.4

3.8

1.6

4.2

2.0

3

1

5

3

4

3

5

0

Catheter hours

2189

2323

2667

2736

2374

3736

27058

37971

Catheter days

91.2

96.8

111.1

114.0

98.9

155.7

1127.4

1582.1

CRI/100 days

32.9

10.3

45.0

26.3

40.4

19.3

4.4

0.0

% of MV with VAP VAP/1000 ventilator days Catheter-related infections (n)

7

6

Abbreviations: CRI, catheter-related infections; VAP, ventilator-associated pneumonias.



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Fate of QI program challenges identified in 2006

The 2006 study found 4 key challenges for the ¨ oping ¨ Jonk QI program. The first was the capacity to show evidence of improved outcomes for patients, which we addressed. The 3 other challenges were as follows: physician involvement; the clinical information system; and the management, processing, and interpretation of quality improvement data. We revisit those issues here, to show how the JCC and its QI program managed to (or did not) deal with them.

Figure 3. Risk and outcome of sepsis, pneumonia, and peritonitis, Ryhov.

were required to display their results. When the Ryhov chief medical officer (CMO) and the chief nursing officer (CNO) visited, the display was part of the dialog and so were the department’s postings on the intranet. With regard to primary care in the area, our informant did not have to think long to come up with improvement projects and results in that field:

So the National Board [of Health and Welfare] would say that those kind of antibiotics shouldn´t be used, you should prefer 3 other types of antibiotics that you should change between. So, we made a follow-up [assessment] and we saw that there was not a very good result from the beginning. And then we had a clinical guideline written, we had education around it and then last year we had a follow-up and improved quite well . . . up to almost 100% [adherence]. Primary care physician Informants argued that each department could show quite a lot of evidence of clinical improvement. However, at this stage, this study was not able to include these results as evidence of outcome improvement, sometimes because of data collection or data interpretation issues, sometimes because we classified the data as process rather than outcome measures. Some leaders also mentioned other progress in outcomes, but as the evidence was not available, this study could not take it into account. It can only be speculated that there is more in the pipeline and that new research in a few years’ time may well show improved outcomes in other areas. The question of performance improvement appeared even more difficult to answer from a hospital-wide perspective.

Most or probably all the departments have some form of clinical improvement. ( . . . ) If you ask the same question for hospital-wide figures, then we maybe have a more difficult time answering that. Senior manager 3

Physician involvement In 2006, the commitment of JCC physicians toward QI varied considerably. While the leaders of QI within clinical departments were usually physicians, many had little ambition to be deeply involved. There was, however, no open hostility toward the improvement program; a few interviewees suggested that the physician culture was at a “tipping point.” With some departments showing process or outcomes improvements, after 15 years of sustained commitment to a QI program, attitudes were becoming more open to QI. In August 2010, informants agreed that physicians were more involved in QI than 4 years earlier. The culture, by then, was clearly more open to QI; the number of clinical leaders with only little or no ambition for involvement in QI had decreased. Nevertheless, informants indicated that there was still a long way to go on this topic and that physician involvement remained a challenge and needed to be strengthened. While low-grade, there was still some resistance toward Qulturum’s initiatives and clearly not all physicians were on board.

I think that the physician involvement is much better, still it can be better, but it´s better than 4 years ago. When you have started with patient safety you become also interested in clinical improvement. Mats Bojestig, CMO, ¨ oping ¨ Jonk County Council Qulturum’s program for patient safety has been I think very broad and good and with good methods and that way I think that some of the units don´t even think of it as a Qulturum thing anymore, because some clinicians have resistance to that. Senior manger 1 When asked to explain the increased involvement of physicians, informants pointed to the following circumstances: r The attention paid to Patient Safety had been a door opener. Patient Safety made it possible for hospital CEOs to discuss accountability with physicians and to create a dialog on some issues relating to clinical practice or clinical organization. r The national Open Comparisons made it possible to centralize data on clinical improvement (earlier, some department heads had been reluctant



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r r

to share such data with management), to offer feedback to physicians and undertake benchmarking. Some clinical leaders that were not very engaged left the organization; with successors being more involved. Starting to teach QI during physician’s residency helped promote the culture that improving one’s work is part of the job.

Clinical information system In 2006, we noted that JCC was quite far from its potential in clinical information systems. This—we argued— prevented the organization from capturing data on QI. At that time, there were big hopes for the introduction of an electronic clinical information system. Only primary care already had such a system. The new system to integrate the whole organization had already been selected and was due to be deployed within 2 years. By 2010, however, the system was just starting to be deployed. Hopes were still high, but disappointment was even higher. This is the only topic where interviews revealed some anger among informants. The disappointment was the highest in Primary care, as this sector already had a clinical information system in the past. Some informants mentioned that suggestions had not been listened to; others that the lessons from the pilot sites had not been learned fast enough. All informants with whom the issue was discussed agreed that there was widespread disappointment and that this topic remained a weakness. One informant considered that the clinical information system project had been run neither according to the QI principles along which most other projects were usually run, nor according to risk management and safety principles. A clinician informant indicated that in his department, the information system was with no doubt the single most criticized issue among colleagues. For the chief medical officer (CMO), who led the design and the implementation of this new clinical information system, the challenge was a difficult one. It constituted more than a project, rather a major endeavor. He argued that the information system was not at the technical level, it was assumed to be when it was chosen, and that there had been an underestimation of the number of people who were needed for its customization and implementation. Previously, each department had its own medical record. Now it was becoming a single record. Decision support should be integrated into the system, but that was still far into the future. In the version that was being deployed, clinical guidelines were not integrated in the clinical information system. Data management, processing, and interpretation In 2006, we noted that each department, sometimes each unit, had developed its own tools and methods for measurement and data collection in QI initiatives. There was no standardization of measurement tools, of rules for interpretation or of data presentation. Often, QI data were kept on local Excel spreadsheets and

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were not integrated in a clinical information system. The organization relied on 0.6 Full-time equivalent (FTE) of a professional data manager. The JCC infrastructure for data collection and presentation to senior management evolved between 2006 and 2010, though slowly. The JCC’s emphasis remained on making sure data reached the microsystems and not on data centralization. The idea was that the microsystem had to own the measurement and that was what was happening. Some informants suggested that there should not be a contradiction between providing data to frontline microsystems and to the center of the JCC. The partnership with IHI during the Pursuing Perfection Collaborative (2001-2008)27 came to an end, but JCC entered a new arrangement with IHI that allowed continuing collaboration. A program called “Measurement for Management,” offered by Qulturum with IHI input28 and open to teams from across Sweden, was created following the 2006 study, to help participants build system-level capacity for measurement, data collection, and interpretation. The Chief of Learning and Innovation had been involved in numerous efforts to develop JCC “system measures,” a set of indicators to summarize and integrate data on the global functioning and performance of the whole system,28 which could become an eye opener. The County had a few of those measures, but a respondent observed that it was very difficult to design such indicators and populate them with data. There was ongoing debate about them. In 2010, informants indicated that data centralization and management had improved, but that the County Council still could do much better. There was a monthly dashboard with system measures for the Executive Board (Figure 4). There still was no integrated data warehouse that included clinical process and outcomes data. There was, however, more data available than in 2006. Data on access, for example, was really followed closely and everyone knew that the JCC political Board itself looked into it. The same was true for some Patient Safety data like hand hygiene, but not yet for clinical results. One manager mentioned that the use of measures had improved since 2006. Dashboards had become integrated into routine work. He also felt that daily work was much more influenced by the quality measures. By 2010, there was a full-time statistician and data manager, with a quality engineering background. Informants respected his inputs. There were, however, no house rules on how to present data. Sometimes, as reported by an informant, when the statistician was in the room, people started to apologize about their graph axes not starting at zero. Local Excel spreadsheets remained common for data gathering and management, in the absence of a more system-wide approach. Continuing evolution of the QI program in a changing context

We now focus on 5 issues, which emerged in the period 2006-2010, which illustrate the changing context, management, and form of the Improvement Program:



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Figure 4. Dashboard, safe-care program.

r CEO succession r Managing a changing r r r

external context (including the emergence of private providers in primary care and of financial incentives in the hospital sector) Ongoing strategic development (in relation to integration and transparency) Embedding a broader conceptualization of “quality” (incorporating clinical effectiveness, patient safety, and patient experience) Continuing investment in QI education and research

CEO succession Sven-Olof Karlsson was the CEO in charge in 2006. He had been in that position for 17 years and had sponsored the initial steps, as well as the ambitious deployment, of the Improvement Program. He was, and was perceived as, very committed to QI. He retired in 2008. How much of the Improvement Program and of the culture change depended on Sven-Olof Karlsson’s leadership? How did the County Council manage the CEO succession, particularly in relation to its QI program? The new CEO, Agneta Jansmyr, took office in 2008. She had worked for the JCC in the 1990s, contributing to pioneering work on QI. A physiotherapist by training, she had been involved at the start of Qulturum. Among

other tasks and responsibilities, she actually designed the first QI training program and supported the first application process for the Swedish Healthcare Quality Award, based on the Baldrige Award methodology. Informants reported that a lot of people worried when the previous CEO retired. They suggested that the new CEO’s background in QI most probably played a role in her appointment. Some informants were really convinced that the Board was very careful about the commitment to QI in the CEO selection process. The new CEO was considered very knowledgeable about QI. Informants indicated that there had been no change, since she had taken office, in the QI concept or in the ambition of the program. She acknowledged the importance of clinical outcomes. While one informant felt that the new CEO might be less passionate than her predecessor when talking about patient safety, several informants mentioned that they saw even more people involved in QI under her leadership. Some informants suggested that the change of CEO—even if it had not changed the values and the strategy—had revitalized the organization. The members of the leadership group who were the closest to Sven-Olof Karlsson in the QI endeavor reported that they continued to be listened to just the same and that they had the same access to the new CEO that they had to her predecessor.


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One senior manager, when asked about CEO succession and its management, linked the nomination of the new CEO to the organizational culture. There is no doubt that the actual nomination process was a formal one and much more complex than what is worded in this statement, but the link to the culture shows how natural this senior manager thought it was for this nomination to happen, given the organizational culture. The culture here promoted a person who is interested and knows about Quality Improvement. Senior manager 1 When confronted with this statement, other informants thought it mirrored the feelings of a number of members of senior leadership in the organization. A few informants felt that the new CEO was placing less emphasis on international recognition and more on local and national visibility. This was reassuring for some people who were skeptical about the US influence brought in by the former CEO. Others, however, suggested that a lot of the credibility that the JCC had gained nationally and locally came from its international reputation and not the reverse. One informant also observed that the former CEO had only tapped into an international network a number of years into his tenure whereas the new CEO had done so from the beginning, for example, by attending International Forums on QI and IHI strategic partnership meetings. A number of informants said that finding the right balance on that matter was an important issue that, by 2010, had not been much debated. The new CEO, when interviewed, saw her own role in leading QI as setting the goals annually, talking about them, helping the system reach the goals, meeting with leaders in the JCC and reminding them about the values and the goals, as well as involving the politicians and understanding their goals. When asked for her opinion about the vision of the County Council, “For a good life in an attractive county,” she showed true endorsement of the vision and commented that it was a good vision as it was about the people who live in the county and not about the organization. Managing a changing external context In 2006, Sweden changed from a social-democrat to a conservative coalition government, following a longstanding dominance of social-democrat governments. This shift from left to right also occurred at the county ¨ oping. ¨ level in Jonk This had 2 consequences that were ¨ oping ¨ hard to predict on the basis of the culture in Jonk up until 2006: the emergence of private providers in primary care and the introduction of financial incentives in the management of health care services in the County Council. The emergence of private providers in primary care. Mandated by law, spearheaded by the new conservative coalition government, this change had just begun in August 2010. The hope of the proponents of this

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idea was for it to improve access to care, offer patients (and professionals) greater choice of provider (or employer), and stimulate improvement of primary care. One risk that some informants highlighted was creation of temporary overcapacity, as they thought longstanding capacity could not be reduced as quickly as new capacity could appear. The time lag would represent overcapacity, with its associated costs to the system. Some informants also worried about losing integration in the health care system. To manage that emergence, JCC designed its own rules to maintain the integrity of the system as a whole, even with new, contracting providers. Rules included that the new private care providers needed to be connected to the same IT system. They were invited to participate in JCC’s leadership (“Big group health care”) meetings. Aspects of the county council health system considered essential infrastructure—eg, Qulturum and Futurum, the units for development, clinical research, and education—were kept as system-level resources funded centrally, and serving the entire system irrespective of provider organization. Such an arrangement was not used in all county councils in the country, exemplifying the way that they were free to make different arrangements, as long as they complied with the law. The impact on quality of this evolution in the environment was not clear at the time of the case study update. The introduction of financial incentives. In early 2006, setting up a “pay for performance” system between corporate County Council and the various departments was unimaginable, contrary to the local culture. Not long thereafter, the new political majority requested such a system. The CEO in office at that time did not like the idea and most of the members of the leadership group were reluctant. The new CEO saw that it was unavoidable. While the initial idea from the politicians was to incentivize on productivity, the leadership of the County Council also observed that each year, a number of goals that had been defined in the annual budget and strategic plan tended to not be achieved. The County Council leadership therefore geared these financial incentives to stimulating the departments to reach the yearly goals, while upholding its values and strategy, a strategy that avoided incentivizing on volume of visits, or procedures, for example. The model was presented to the Heads of Departments and there was not so much discussion, as it involved reaching goals that preexisted, thus harmonizing with the existing culture. By 2010, 2% of the annual budget was withheld from the departments and paid only if selected performance targets were met. One percent was linked to access and the other percent was tied to measured performance in areas such as hand hygiene, use of the surgical checklist, waiting time in the emergency department, and clinical results in cardiology and stroke. For the first year, a 3-month trial (simulation) allowed all departments to test the system without any actual financial stake. After that, the new system took effect.



Despite widespread skepticism, the concept was seen to have had the desired effect. By August 2010, clinical department leaders would tell their colleagues how important it was to improve access to get the incentive funding. Some clinical leaders went to each of the physicians asking why the target was not fully reached, discussing what could be improved. Some leaders even asked for new items to be included in the incentive program, as a way to help them reach their departmental goals, for example, to include the national target of treating 90% of ER patients within 4 hours after their arrival. The County Council executives reported satisfaction with the system and considered that 2% was enough to make departments focus on their goals and not too high a stake to induce opportunistic behavior. The medical director, initially skeptical about financial incentives, observed that, as far as access was concerned, for instance, the incentive had really focused attention on the process and boosted performance. Ongoing strategic development The JCC remained faithful to its vision, its values, and its key operating principles, notwithstanding the key changes in the political strategies outlined earlier. It creatively integrated the new political directives with its values and QI principles. In 2010, the key tools and principles that were employed in 2006 had been developed, spread, and were used even more meaningfully. We refer to the emphasis on measurement, the use of the balanced scorecard, the use of QI tools, the microsystems theory training, the goal setting, and follow-up system. The vision and the QI strategy had undergone almost no change, even if the emphasis on patient safety had grown. The general bottom-up approach to QI remained, but a new layer of system redesign (institutional initiatives with a common methodology, to improve the care delivery system)—more top-down—had been added, for example, the patient safety initiative, bringing balance between individual and system-wide initiatives. The chief of Learning and Innovation explained that the JCC leaders had developed deeper knowledge of quality and safety improvement, and that political goals had become more and more specific and demanding, bringing new challenges for Qulturum.

The key thing, the value development in a patient perspective, is now no longer an ambition. It is more or less a requirement. ¨ Goran Henriks, Chief of Learning and Innovation, Director of Qulturum Most informants in the clinical departments reported getting support and credit for QI work. One felt that the allocated resources did not match the verbal support. One insisted that the culture was that the units undertaking improvement work were recognized by the other

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units. No informant complained of getting no recognition for improvement work. Transparency. Each year, the County Council publishes its budget, its accounts, its volume of services provided, various indicators, its strategy, and goals openly on the Internet. All of these items were included in 2006 and remained since then. By 2010, though, the previous year’s goals were shown too, with results achieved. Comments, as well as green, yellow, and red “signal lights,” showed if they had been reached or not. This increased transparency also constituted a pressure that the County Council had set on itself to reach its own goals. Yet, one informant suggested that the increased transparency on performance had not yet sufficiently included situations where patients are harmed (open reporting of serious adverse events). To his view, transparency in the daily work still had to be won. Integration. The JCC had integrated primary and secondary care in innovative ways. A general practitioner coordinated a network of stakeholders to design guidelines on how primary and secondary care should work together, with inspiration from Denmark. By 2010, every department at Ryhov hospital had a general practitioner advisor, for the cooperation with primary care and for the clinical work. This advisor helped define which tests should be done where, how to deal with a specific group of patients, when to refer a patient back to primary care, etc. In 2008, this system was spread to the entire county and by 2010 there was only 1 set of guidelines for the whole system. The system dealt with contacts between physicians, but also other professionals: nurses, physical therapists, midwives, etc. There were 23 teams working with different patient groups: pediatrics, geriatrics, cardiology, surgery, eye diseases, etc. The guidelines that they produced were short (2-3 pages) and did not only cover the medical aspect, but all aspects of care. There were about 150 such guidelines by 2010. For example, the guideline on depression was based on a recent national guideline and included a scoring scale, to assess which cases should be treated in primary care, and which were severe depressions with suicidality, to be dealt with by specialized psychiatry. Embedding a broader conceptualization of “quality” ¨ oping ¨ Jonk County Council’s improvement efforts have been guided by the 6 key dimensions of Health Care Quality highlighted by the Institute of Medicine: safety, timeliness, effectiveness, efficiency, equitability, and patient centeredness.29 ¨ oping ¨ Jonk County Council’s work on timeliness (access to care) and on efficiency has already been described.10 To broaden its approach to quality according to the Institute of Medicine dimensions, the JCC expanded its emphasis on patient involvement, implementation of evidence-based medicine, and patient safety during the period 2006-2010.


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Patient involvement. Patient involvement had developed since 2006 and become a key feature of the Improvement Program, according to several informants. Many comments highlighted the importance of involving patients:

I think it´s an important thing when you get the patients inside the improvement work. It´s important to change perspective. Qulturum Project Coordinator The most important thing is to work with patients and involving patients ( . . . ), in new ways and much more than before. Agneta Jansmyr, ¨ oping ¨ CEO, Jonk County Council The JCC maintained its Patient Direct Channel—a way for patients to contact independent representatives to resolve concerns, in place already in the previous study. In addition, by 2010, the JCC Patient Safety Board included a patient representative. Qulturum launched a program called “Together with patients,” an initiative that originated from the Patient Safety Board. It started with a pilot project in the Emergency Department, which involved a patient in the work group, to address information, communication, how the patient was welcomed, what first met the eye upon arrival, where one could get food, or where to park. Then the dialysis unit also joined the “Together” initiative. Prompted by a patient who ventured to manage the whole dialysis procedure by himself, the unit developed a facility for self-dialysis, inaugurated by a member of the Royal family, himself a renal failure patient. Another project concerned how to prepare patients for moving to a ward when discharged from the ICU, to prevent them from feeling abandoned when they suddenly became much less watched. Qulturum published a book written by a patient,30 which conveys a patient’s experience and perspective. The author suffered a series of complications from treatment within one of the County Council’s facilities. The book mixes the patient’s experience, with extracts from her diary, from her relatives’ diary, from her medical record, offering readers food for thought. Its purpose was also to be used for staff training in the JCC. Use of clinical guidelines and evidence-based medicine. In the 2006 case study, the clearest and most convincing clinical outcome improvement (reducing admissions for acute asthma in pediatrics) was associated with the implementation of an evidence-based prevention process. In pediatrics, by 2010, we observed that the work with guidelines had spread to additional areas. The department used 2-page summaries of guidelines, at the point of care. Despite an increased spread and use of guidelines, one of our informants observed that there was a lot of variability across departments in guideline implementation, noting that if you had an interested doctor who read a lot about new guidelines, whom others listened

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to, this would increase the probability of guideline implementation. Another informant suggested that it was still challenging to get the guidelines used consistently. It was hard to know the degree of guideline adherence and clinical practice was still largely left to each individual physician. According to this informant, the organization needed to migrate to a new stage where things would be more rooted in the system. The JCC chief medical officer led a national committee focused on how guidelines were designed and used in Sweden. He believed that there was room for a new vision, for more shared work to integrate guidelines with electronic medical records and to build-in Patient Safety and Improvement concepts. He also noted the need to collaborate more closely with the National Quality Registers and to increase the use of feedback data from registers when updating or redesigning guidelines, integrating all this for knowledge-based care, as well as with educational programs. He envisioned a future where daily care could really be supported by a knowledge system, with every clinician getting regular feedback on her or his own process and outcomes data, far beyond the current situation, which frequently involves only once-yearly updates on outcomes. A clinician from Internal Medicine reported on a research and improvement initiative. It involved redesigning the care for patients with atrial fibrillation to achieve better outcomes. The clinician explained that current practice was not evidence-based, the most important problem being insufficient use of warfarin (an anticoagulant to prevent blood clotting). The intervention included guideline dissemination, an algorithm provided in pocket size and a training for all emergency room doctors. An outpatient clinic with extended hours of operation was also set up, to make it safer to send patients home as they have a mean to come back during extended hours. A checklist was also developed for physicians to go through with the patient. A quality of life survey (SF 36) was used for the assessment, which also concerned the process of guideline implementation and costs. Patient safety initiatives. Patient Safety work within JCC started explicitly under this title in 2003, in line with national and international developments.31 Senior managers described the evolution since 2006, in Patient Safety, as moving from a set of projects to system planning.

I think that we have had a lot of projects; we are now much more working on the broad base, it´s much more integrated in the system than 4 years ago. Mats Bojestig, CMO, ¨ oping ¨ Jonk County Council Our awareness and our approach have been quite profound, in a way. We have developed performance in patient safety areas that we didn´t have in 2006. And I think that we now have knowledge



and understanding that are ready to build a much more reliable system. ¨ Goran Henriks, Chief of Learning and Innovation, Director of Qulturum An institutional Patient Safety Program, called “Safe Health Care every time, all the time,” was in place by 2010, including 14 focus areas (see Figure 5). The program was based on the 2 IHI-led US campaigns “Saving 100 000 lives” and “Saving 5 million lives from harm.”32 Drawing on these, the JCC identified 12 focus areas for patient safety. It added 2 areas from a national campaign (which had 6 areas, with 4 overlapping with the US campaigns). Patient Safety, between 2006 and 2010, was seen by informants as a door opener to QI. It allowed the organization to raise important issues in the field of clinical quality, while being met by a more welcoming attitude among clinicians. Each spring, Ryhov’s CNO and its CMO visited all 23 departments in their organization and, with each, reviewed all of the 14 Patient Safety focus areas. It was called the “Patient Safety Dialogue,” modeled on so-called safety walk-rounds,33 spearheaded in Sweden ¨ ¨ by neighboring Osterg otland County Council in 2005.34 The discussion covered the measurements and results; how well the team was informed on countywide programs. The meeting included not only the unit leaders but also 5 to 10 staff members. An informant who witnessed the process explained that, following a series of visits, the CNO and the CMO had presented the results of their Safety Dialog. They identified 7 departments with a high level of patient safety work and involvement, 5 with moderate involvement, and 2 which were not really working with the issue. Consequently, these 2 immediately developed their safety work.

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The work on preventing Pressure Ulcers and Falls was supported with a new national quality register called “Senior Alert,” initiated and managed in ¨ oping. ¨ Jonk With guidance from the register, patients older than 65 years were assessed for their risk of falls, pressure ulcers, and malnutrition, by any care provider they met (home care, primary care, hospital, . . . ). When the patient came to a new facility, there was a new assessment and it was fed into the database. As part of the register, prevention strategies were suggested, at the point of care, based on each patient’s data. Root cause analyses were compulsory for all cases involving a death or other major adverse event. The ambition had been clearly raised within the past years. At Ryhov hospital, about 30 root cause analyses were performed per year. The hospital also promoted Failure Mode and Effects Analyses and had been creating a Failure Mode and Effects Analyses database, intended for professionals to look up common issues. Among the indicators used to monitor outcomes improvement were 2 Trigger Tools, 1 Global and 1 specific for Adverse Drug Events, developed by the Institute for Healthcare Improvement.35,36 Despite an ambitious improvement program in Patient Safety, a few informants still considered that the County Council’s investment in Patient Safety was far below what was needed to truly impact clinical outcomes. They argued that the prevalence of adverse events, as measured by the 2 Trigger Tools that JCC used, had remained rather flat (stable process, from a statistical process control point of view), despite a number of improvement initiatives. Their feeling was that the topics that had been selected for improvement were the right ones, but that the ambition of the system redesign needed to be much greater, as did the

Figure 5. The 14 patient safety focus areas.


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shift in culture. One informant commented that leaders were not sufficiently connected personally to adverse events within the institution.

Maybe I should be satisfied but I don´t see that fast improvement that I actually would like to see. We still have a lot of medical errors; we still do a lousy job sometimes. Senior manager 2 One informant thought the problem with the Adverse Drug Event Trigger Tool was that the County Council started measuring but for a number of years did not launch improvement work specific to that area. Despite the rather flat looking control charts on the Global Trigger Tool results, (ie, not displaying any clear improvement signals) the medical advisor of Ryhov hospital, together with the hospital management, set a goal of reducing adverse events by 50%. The thinking was that despite the wide-ranging improvement program being deployed, the global level remained unacceptable and that Patient Safety was still considered a project, carried out only when people had “spare” time. The Global Trigger Tool had been part of a 3-hour leadership meeting at the hospital, every clinical leader going through one demonstration patient chart. The idea was that Trigger Tool results had been collected for a number of years, but not sufficiently fed back to clinicians, and that doing so and truly focusing on Patient Safety still allowed a 50% improvement target. The chief of Learning and Innovation agreed that while some initiatives—like hand hygiene—were implemented systematically, others had not been as clearly defined and it was sometimes not yet completely clear what people should be doing. For example, one difficulty encountered was that for Acute Myocardial Infarction care, the quality register had not yet incorporated modern safety thinking. But in heart failure, things were moving forward, with preventive, upstream work under way. At the same time as the County Council was hearing some people say that the program could be more ambitious, it was also getting some resistance from staff who argued that 14 focus areas were too many and that teams could not be expected to work with so many guidelines and check-lists, as one interviewee expressed. Continuing investment in QI education and research ¨ oping ¨ Jonk County Council believes there is synergy between QI, clinical research, continuous education, and QI research. The Futurum academy was set up for that purpose. It promotes, organizes, and supports clinical research within the JCC and arranges clinical training for a wide range of health professions ¨ students, be they from the medical school at Linkoping ¨ oping ¨ University, the School of Health Sciences at Jonk University, or from elsewhere. Futurum also offers a health care library with skilled librarians. They support not only researchers but also clinicians and students in their regular work. One of our informants described the

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health care system in general as an “extreme knowledge organization”—meaning that one needs these kinds of structures to support the continuous flow of knowledge and to put new knowledge into action— which is why such an infrastructure is considered so vital for the JCC. Supported by a national research grant in 2007 for “Bridging the Gaps,” Futurum brought together re¨ searchers from the universities in Uppsala, Linkoping, ¨ o¨ and the 4 schools of Jonk ¨ oping ¨ and Vaxj University (business, engineering, learning and communication, and health sciences) to create a network for research on health care improvement and leadership. The initiative included a PhD program coordinated by the director of Futurum, working in a matrix organization with the participating universities. Since the middle of the 1980s, the County Council had supported about 8 half-time positions for PhD students affiliated with different universities. One informant emphasized that it was attractive to work in a county where one could also get support to carry out clinical research, sometimes even more so than at the university hospital. Promoting research on site supports a research culture, which influences the clinical culture; clinical practices are continuously questioned and reviewed, in the spirit of evidence-based medicine and practice. Active, local, research also helps to involve physicians in QI.

Many studies have shown that one of the keys to improvement work is to get physicians on board. And if you don´t have solid data that these methods or thinking make a difference, they will not be interested. So that´s one of the main clues I think to get physicians on board. Senior manager 1 Encouraged by the success of the “Bridging the gaps” initiative, and an additional grant to develop a Master’s program on QI and leadership, the JCC part¨ oping ¨ nered in 2009 with Jonk University and the 13 ¨ oping ¨ municipalities in the County, to create the Jonk Academy for Improvement of Health and Welfare. In just a few months, the new Academy launched a multiprofessional Master’s program for current and emerging leaders in health and social care, building on earlier educational programs co-sponsored by the JCC, and supported by close collaboration with the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth Medical School in New Hampshire, United States. The University recruited Professor Paul Batalden, MD, pioneer in Healthcare QI,37 co-founder of the Institute for Healthcare Improvement and a leading researcher from Dartmouth, for a part-time position at the Academy. The JCC has encouraged some of its employees in clinical and/or managerial positions to join the Master’s program and supported them with salaried time for their studies. Quality improvement had also been integrated into the education program for residents. The program “ST-LEKA” also included leadership, ethics, and



administration. It was a 9-day program, spread out over time, to meet new national training requirements for residents. One informant, in the process of taking the course, said that before attending, he thought it was nonsense to invest time on these topics, but that after the course he was impressed and very interested with each topic. Furthermore, undergraduate students were involved in QI activities during their rotations. By 2010, about 2000 employees had been trained in microsystem theory. In other words, learning, improvement, and knowledge generation were integral to the JCC health care system. DISCUSSION ¨ oping ¨ A striking aspect of Jonk County Council’s evolution between 2006 and 2010 is how it managed to sustain and develop its Quality and Safety Improvement Strategy in an environment that could have led observers to predict the reverse. The County Council had the privilege of having a CEO who got interested early in QI, when it was only emerging in health care. He led his organization to join the pioneers and it never left. With a team of innovators, he created a stable environment and fostered a culture of continuous improvement. When he left, after 19 years, a remarkably long and successful tenure, it was only natural to wonder how the County Council would do without the father of the Improvement Program. This case study found consensus among informants that JCC thrived despite the challenge. It managed to recruit a CEO who was already knowledgeable about QI and who kept it as a central part of the strategy. The longstanding and loyal team of innovators was kept motivated. New developments have taken place at a pace that is consistent with the leadership role in quality that JCC has claimed in Sweden and internationally. There was more than 1 challenge during the 2006 to 2010 period, however. The shift in political majority led to the emergence of private providers in primary care. This was a challenge to the culture and to the structure of JCC. It was addressed with anticipation and professionalism. Risks (loosing integration and continuity of care) were identified and analyzed and a strategy to control them was deployed. Resources were invested in managing the challenge. A new department for primary care was created so that there would be adequate responsiveness to emerging issues. The same happened with the introduction of financial incentives. Despite the shock to the values, risks (opportunistic behavior, increased consumption of care) were identified and addressed. An opportunity to stimulate the pace of reaching quality goals was seen and taken. Here also, resources were invested in carefully designing an incentive system that would simultaneously address the new political requirements and espouse the values of continuous improvement, as well as fit the strategic priorities10,11 of the QI program, such as access to care and patient safety. Simultaneously, the national agenda for clinical improvement and patient safety developed ¨ oping ¨ rapidly. Jonk County Council used it as an opportunity to stimulate its clinicians and has included

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the topic of how to use clinical registers in its continuous education program. The Open Comparisons and the developing awareness of patient safety were used as door openers to get the attention of clinical leaders. Evidence-based practice guidelines, in 2010, were not used in all departments and to full potential, but it is interesting to observe that they were definitely developed as a strategy in the 2 departments where outcomes improvement can be shown. In areas that gained attention nationally and internationally, such as patient involvement, JCC managed to demonstrate its talent for innovation and keep the lead. The publication of a book on the lessons from an adverse event, as a joint venture between Qulturum, and the patient who experienced it is not something common. It exemplifies an ongoing system-wide effort to engage patients and to redesign care with their help. Consistent with its longstanding strategy, JCC managed to integrate new goals, new tools, and new initiatives and its improvement program without renouncing its philosophy and values. The evolution was smoothly integrated into the action plan. This does not happen by accident. The leaders of the improvement program make it a point to be aware of every innovation, tool, methodology that appears on the radar of quality in health care. This happens through active participation in congresses on the topic, when delegates ¨ oping ¨ from Jonk are dispatched to different sessions to maximize the spectrum of new knowledge gleaned and through debriefing after such conferences to capture the knowledge and assess its local potential. Then, experience has shown that a filtering mechanism is needed. When JCC participated in the IHI collaborative called “Pursuing Perfection,” there was some mismatch between that terminology and the Swedish health care culture. The improvement program leaders have therefore devised ways of taking the best out of international innovations and then of reframing them or renaming—adapting—them to fit the culture. This is illustrated in the way that a number of principles from “lean,”38 which, elsewhere, have been associated with cost reduction and fear of job losses, were integrated into the clinical microsystem efforts. Principles that were developed within the car manufacturing industry are well translated and adapted to Swedish health care in collaboration with leaders from the Dartmouth Institute who spearheaded the microsystem concept.39,40 The County Council thus combines a “Lego” strategy, picking pieces from a variety of QI concepts and assembling them for what it considers the wisest use, with a reframing strategy, labeling the concepts with words that are emotionally and culturally compatible with Swedish health care. The same filtering mechanism, however, also includes foregoing some innovations that would be perceived as U-turns in the improvement strategy or that would have little potential to fit in the culture, mirroring Walshe and Freeman’s41 proposition that it is more important to stick to a quality strategy and continuously refine it than to constantly skip from one to the next, trying to find “the best” strategy, an elusive goal. This filtering and tailoring process also well


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illustrates the management of the cultural and the emotional challenge of QI programs identified by Bate et al.1 What about holding the gains in terms of clinical results?

The 2006 case study10 showed a strong emphasis on a bottom-up approach to QI, with the benefit of high enthusiasm and goodwill, but with difficulties in spreading best practice. One area was an exception to that philosophy: improvement in access to care was led through a corporate initiative. In 2010, we found a more balanced approach between bottom-up initiatives and topdown initiatives, like the portfolio of 14 improvement areas regarding patient safety. These had a strong corporate impulse and were based on external initiatives, with methodologies, implementation, and measurement tools drawn from these campaigns. Here, the emphasis was not on “inventing and exporting best practice,” as in the bottom-up initiatives, but on importing and emulating best practice. Creativity and participation was focused on how to adjust to the local context. This approach of combining bottom-up and a top-down approaches to improvement has been described42 as a “pincer strategy,” which can allow organizations to “harness the insights and motivation of [improvement] team members, while aligning improvement efforts with [strategic], organizational, priorities.”43 The 2006 case study of JCC10 proposed the hypothesis of an investment threshold for QI programs. The investment refers to the infrastructure and skills for QI that need to be created, including the information technology, and also the “soft” infrastructure such as awareness, leadership will and commitment, the political process of freeing up resources for QI, training staff, building culture, setting up indicators and data collection systems, and testing QI tools. As long as the investment threshold is not reached, the impact of QI work does not show on patient results. The QI efforts do not make a clear signal above the “noise” of ordinary performance. In 2006, one clinical department, Pediatrics, was able to show evidence of outcomes improvement, suggesting that it had crossed the investment threshold. By 2010, this department had sustained its results on child asthma and had intensified its QI initiatives. The Department of Intensive Care also showed evidence of clinical outcomes improvement. This is consistent with the hypothesis of an investment threshold and suggests that, now that the infrastructure is in place and sustained, new departments cross the investment threshold and are able to show improved clinical outcomes. At a JCC system level, its consistently high rankings on the national Open Comparisons further indicate favorable patient outcomes, even if the link to the JCC QI program is difficult to establish. With the leadership will, the learning culture, and the capability to capture new ideas for improvement that characterize JCC, one can wonder why there are not more departments that show improved clinical outcomes. Part of the reasons are certainly linked to the

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classical limitations of outcomes indicators, well summarized by Mainz.44 The outcome is indeed determined by features of the patient, the illness, the treatment, and the organization. Here we mainly look into the treatment and the organization. Mainz also highlights the difficulty to adjust for risk, to control confounding factors, to have enough cases over a defined time ¨ oping, ¨ period, etc. In the case of Jonk we can see that the departments with improved outcomes have worked with evidence-based guidelines and their systematic implementation. Perhaps other departments could learn from such guideline implementation. Not all areas of medicine offer a range of evidence-based guidelines. But where they exist, there might well be extra potential. Both, on the one hand, because their reliable, systematic, and context-specific implementation does increase the probability of improved patient outcomes, and, on the other hand, because they are associated with indicators that stimulate improvement, a culture of questioning current practice and learning from data. As described in the findings, 2 of the 3 QI challenges that were observed in 2006, that is, physician involvement—relating to the political and emotional challenges in Bate et al framework—and the management, processing, interpretation, and accessibility of QI data had receded as challenges in 2010. However, they still remained latent. Furthermore, the JCC clinical information system still had significant shortcomings in 2010, for example, the difficulties to record process and outcomes measures at the bedside to demonstrate improved performance. It could therefore be that there are other process or outcomes improvement within the JCC system, but that they are not captured by the information system, processed and interpreted. This mirrors what Bate et al1 call the technological challenge. It raises the question, in light of the theoretical proposition that demonstration of impact is central to the long-term support of an improvement program,11 why organizations keep investing in it when such demonstration does not occur. Could this reflect an understanding or an intuition of the investment threshold10 phenomenon? Or, is it perhaps partly a matter of faith, or is it due to recognition that there is a dearth of clearly superior alternatives for how to manage health care and its quality? The concept of perseverance and sustaining the investment to move past the “investment threshold” is close to the concept of persistence and constancy of purpose advocated by Deming,45,46 and suggested by Bate et al1 when discussing the quality journey of Cedars-Sinai, emphasizing the “capacity of the organization to continually learn and improve itself.” The Cedars-Sinai case study shows a number of parallels with that of JCC including “the extent to which sustained QI depends on learning that is organizational as opposed to merely individual . . . the role of boundary spanners in exploring and exploiting new ideas, and of a learning infrastructure in sharing and vetting knowledge throughout the institution and supporting improvement activities through facilitation and expertise.”1



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And just as at Cedars-Sinai, JCC has undertaken— over a significant period of time—the “fundamental process of embedding learning and improvement in the organization by anchoring the quality agenda in the identity and culture of the institution.”1 ¨ oping ¨ The case of Jonk County Council (JCC) illustrates both improvement program durability and sustainability. Durability, we suggest, is the ability to perform over a long period, to hold out against wear ¨ oping ¨ and decay. Jonk County Council has been able to keep the QI program as a strategic priority even in times of budget cuts, of changes to political majorities and agendas. Its QI program has evolved and lasted for over 20 years. However, the key traits of JCC are in sustainability: we consider improvement program sustainability to mark an organization’s ability to maintain and harness benefits after a “project” phase or after initial implementation, to match resources, culture, leadership with the program’s—indeed, with the organization’s mission-critical—needs in the long run, including the necessary reinventing prompted by major changes in the environment. Batalden and colleagues47,48 argue that QI sustainability in health care requires synergistically pursuing 3 interconnected goals: better patient and population outcomes, better system performance and better professional develop¨ oping ¨ ment. Jonk County Council exhibits efforts in all 3 areas, which helps explain how its QI program has been sustained for so long. Yet, important challenges remain, such as reaching even broader and deeper clinician involvement in QI. In similar vein, when studying sustainability, Wiltsey Stirman and colleagues49 suggest investigating

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r whether,

and to what extent, the core elements are maintained; r the extent to which desired health benefits are maintained or improved upon over time ( . . . ); r the extent, nature and impact of modifications to the core and adaptable/peripheral elements of the program or innovation; and r continued capacity to function at the required level to maintain the desired benefits.” Applying this framework (see Table 2), we can see that the JCC learning culture has remained over 20 years, and that QI has become part of the culture of the organization. Even when the CEO left, the new CEO was chosen to perpetuate this core part of JCC’s identity. Furthermore, resources have been stable over the years. For more than 10 years, Qulturum’s staff resources amounted to around 16 FTEs. Even in times of severe budget reductions for the organization, these resources were maintained. When adding a new institutional patient safety program covering 14 areas, extra resources were not added. The JCC resources allocated to the program seem to be those that the organization can support in the long run. The number of FTEs may seem modest when considering the ambition of JCC’s improvement program. Our observation, however, is that the leaders of the improvement program have been very ingenious and capable in attracting grants and national resources. This has allowed JCC to employ project leaders and experts on top of its ordinary budget. To obtain these extra resources, the JCC has often played a role of pilot site and then flagship of national improvement programs in quality or safety. A recent example is the “Measurement for

Table 2. Framework to Investigate Sustainability and Case Study Highlights Investigation Framework

Findings From the JCC Case Study

Define sustainability

We investigate how the QI program and specifically its outcomes and benefits, as assessed in January 2006, were maintained and developed by August 2010.

Whether, and to what extent, the core elements are maintained

The vision, the strategy, and the implementation structure are maintained. The action plan has been extended and is much more ambitious on patient safety in 2010 than in 2006.

The extent to which desired health benefits are maintained or improved upon over time

The department that was able to show improved clinical outcomes in 2006 (pediatrics) continued to improve the benefits for patients in 2010 and extended them to new areas. A second department (intensive care) showed improved clinical outcomes in 2010. JCC ranked in the top of a composite of the National Open Comparison outcomes indicators by 2010.

The extent, nature, and impact of modifications to the core and adaptable/peripheral elements of the program or innovation

The core of the Improvement Program has remained very stable. The weaknesses identified in 2006, and reviewed in 2010 (physician involvement, clinical information system, data management), had been addressed to varying extents. Two of the 3 had improved. To the bottom-up improvement strategy, an ambitious set of corporate initiatives on patient safety had been added.

Continued capacity to function at the required level to maintain the desired benefits

The capacity to function at the level to maintain the benefits (eg, QI support, institution-wide initiatives, governance of clinical activity, data management, QI culture, education, and research) was maintained and developed between 2006 and 2010.

Abbreviation: JCC, J¨onk¨oping County Council; QI, quality improvement.


36


Management” program, which JCC developed and ran with the IHI, and which attracted paying teams from around the country. Qulturum’s resources and the continued investment in this infrastructure—which provides methods’ support, project management, and training—illustrate how JCC deals with what Bate et al1 described as the structural and the educational challenge for QI programs. Here is how we can summarize our findings about sustainability within JCC’s QI program, within the framework to investigate sustainability suggested by Wiltsey Stirman and colleagues.49 Further research/limitations

While covering an unusually long-lasting health care improvement program, this research relied on data collection during 2 site visits. Because of feasibility constraints, we relied on retrospective data collected through interviews and document studies, complemented by observations. A more longitudinal study, with continuous or repeated data collection over time, likely could have yielded even deeper insight into these matters. This case study does not address the financial performance of the JCC in connection with the QI program, other than to note that the JCC has maintained overall financial stability during the time of interest here. Another limitation is some dependence on performance data collected by the study organization, rather than independently by the co-authors or others external to the system. To maximize reliability, we used triangulation between sources of data, confronting perceptions stated by informants with JCC quantitative data and observation, in turn checked for consistency through comparison with external published data. As proposed previously,11 however, the ability of an organization to demonstrate the impact of its improvement program is in itself a marker of its effectiveness. The increasing use of quality registers does offer better access to independently appraised performance data but was not widely referred to in the fieldwork. Another challenge with this study is the language barrier; interviews were carried out in English, which likely constrained some of the respondents’ ability to provide accurate and extensive information. Triangulation through comparing responses from multiple respondents, and from documents, should compensate for this limitation to some extent. In sum, these limitations call for some caution in interpreting the findings. Nevertheless, this study does add to the evidence base for the potential impact of a system-wide QI program and for its sustainability in a changing environment. Further research is needed to develop our understanding of the existence of an investment threshold for an improvement program, whether and how it can be lowered, to enable organizations to achieve and demonstrate system-wide improvement sooner than is common today. Longitudinal research, including interactive or action research approaches,50,51 could help advance both theory and practice in this area.

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