Every year, Qulturum – the development unit of Jönköping County Council, Sweden – hosts a variety of study visits. The visits are not only a way to provide our visitors information about our improvement work and methods, but also an opportunity for us to learn from the experiences of others. We are together creating, not only a worldwide network of engaged and inspired Health Care workers, but also an environment of co-learning.
What do we mean by Co-Learning meetings?
The idea behind the co-learning meeting can be illustrated by the following picture;
A Co-Learning meeting is a type of meeting which can be compared to the River of Consultations; people exchange their experiences, use different tools and methods to build their knowledge, they reflect upon it and successively build a deeper understanding of what they have heard and learned about.
At Qulturum, we believe that the best means of building and developing the deepest understanding is through dialogue.
A dialogue allows us to exchange ideas and to create new ones. Ideas that can even prove to be revolutionary. We do wish for this kind of revolutionary exchange of ideas with our guests and this is why we prefer to call study visits co-learning meetings. In the co-learning spirit we live by the saying "It takes two to tango", therefore we wish you to exchange your experiences with us.
Study Visit/Co-Learning Areas
If you wish to come to us in order to learn from one another you should let us know about it at least three months in advance. We treat each encounter individually and, therefore, we need time to be able to prepare ourselves in the best possible way.
Steps of the planning process:
1. Filling in the electronic form "Inquiry Study Visit/Co-Learning" with all the information required
2. Deciding together on the most suitable date for your arrival
3. Booking of the hotel/the flight and other means of transportation. More information here
4. Discussing your area of interest and what you would like to see and hear about. What can you teach us? How can you help us to improve our organization? Et cetera
6. Planning. The practical planning; the program for your stay, places to eat, other practical tips/issues
7. During your stay, we expect you to document your thoughts on Google Documents. You will receive a link with a document in which you will share your reflections
At Qulturum we have several years of experience of co-learning meetings. We have identified some areas that usually are of most interest for our visitors:
- Patient Involvement
- Patient Safety
- Primary Care
- Workshop: Creating memories for the future
- Quality, Innovation and Leadership
Patient involvement is about building bridges between health care providers, patients and their relatives. It is about creating a relationship based on mutual learning. The aim is to actively make use of patients and relatives experiences and knowledge while improving healthcare and managing patients' safety.
Steps to achieve greater patient involvement:
- To educate not only health care providers but also patients and relatives
- To develop new ways of working and a culture where patients and relatives' experiences are utilized in a better way
- To develop models to increase patients and relatives' involvement in their own care and in the development of health care
- To disseminate good examples
Examples of Patient Involvement Offerings:
Esther is a persona that clinicians in Jönköping County Council invented to help them improve patient flow and coordination for seniors in six of the County's municipalities. Care for the elderly is a critical issue in Sweden, one of the countries that have the world's oldest population (18% are aged 65 or older). Esther is an 88-year-old Swedish woman who continues to live alone in the community but has a chronic condition and occasional acute needs.
The Esther network's vision is to create a durable and energetic network in which Esther can feel confident and lead an independent life. In the network Esther coaches keep this vision alive and they support continuous quality improvement.
More information about Esther: http://www.lj.se/index.jsf?nodeId=31383&nodeType=12 (In English)
- Taste of water
The Taste of Water (2011) is an anthology about good care, treatment and ethics based on Anne-May Thorson's diary from her time as inpatient in health care. Added to Anne-May Thorson's story there are comments from professionals in health care which are the ground for a more complex discussion about the important factors for the high quality of care.
- Co-learning with patients – Improving Health Care
Everyone who has in some way experienced health care has their own point of view on what was good and what could be better. Patients/relatives/citizens are still an underutilized resource in improving health care! How can we become better resources for each other? There is one simple answer: we need to do it Together!
The program "Together/Co-learning with patients" started in spring 2010 and it initially consisted of three teams from different departments and clinics and their patients and relatives: Dialysis Unit, Intensive Care Unit, surgical ward and the Emergency Department. In the spring 2011 the psychiatric ward became involved in the program.
"Together/Co-learning with patients" creates the possibility of strengthening patients trust for the personnel and, at the same time, it makes patients more involved in the care process. The greatest advantage for the staff is that taking part of the patients' experiences creates understanding and engagement which, in turn, results in a better and safer care.
The keyword for the better future of health care is ''Together''.
In the northern part of Italy (Trento region), a unique model for care and support of people with psychiatric illnesses has been developed. The Mental health Department of Trento, since 2000 has been actively using the "doing together" approach which implies the involvement of the patients and relatives on a great scale. Jönköping County Council (together with some individual municipalities, Regional Development Council of Jönköping County and some user services) went to Italy to learn how this approach could be applied into a Swedish health care.
What is Patient Safety?
Safer care is something that we can all benefit from; patient feels more secure, employee satisfaction increases and extra cost for mistakes diminishes. We need to be able to learn from the mistakes we make in order to provide safer care. We all lose as long as we have a "guilt culture" where one is punished for making the "wrong".
Changing a culture sets values and attitudes to the test. Increasing the quality of safety requires the organization to review its processes in which different needs can conflict with each other.
Our process of change is a non-punitive safety culture where system accountability and standardization are important concepts.
There is more and more focus on the patient safety worldwide. In the U.S., the number of patients who die from injuries during care and treatment is between 44000-98000 per year (Source: The Quality Chasm 1999). These are deaths which are deemed preventable. In Sweden there are still quite a few studies that demonstrate the scale. The Swedish National Board of Health and Welfare made a study of the incidence of medical injuries in somatic inpatient care.
What we do know is that there is 120 000 injuries registered only in LÖF's (County Council Mutual Insurance Company) database.
Patient safety is achieved when our health care system focuses on what is best for patients. Our vision is to create opportunities to do things correct from the start. Important milestones are:
• preventing the occurrence of errors
• make the incurred errors apparent for the purpose of learning
• prevent the undesirable consequences of any problems arising
Examples of Patient Safety Offerings:
- Safe Health Care – Every Time, All the Time
"Safe Health Care – Every Time, All the Time" is a program to increase patient safety. It is based on the IHI 5 million lives campaign. The program aims to support the improvement of medical care by for example significantly reducing levels of morbidity (illness or medical harm such as adverse drug events or surgical complications) and mortality. 16 areas where improvement is needed are identified and measures are taken in order to improve patient safety.
More information: http://www.lj.se/sakervard (In Swedish)
Good leaders are of a great importance for the success of an organization. This is why Jönköping County Council offers a variety of different measures and programs which aim to improve management/leadership and employees' development.
We offer a variety of programs and trainings: there are permanent training programs at county level, local activities or custom tailored interventions targeted at a specific group at a particular time.
Do you happen to be interested in qualified management development and genuine learning? Then Qulturum is the right place for you, as it is a meeting spot where you can find creative people with passion for leadership and future partners in the strategic and business oriented development. Qulturum offers a fellowship program where leadership is one of many topics on the agenda.
Examples of Leadership Offerings:
- Lean in Health Care
The concept of lean is evolving and spreading throughout different businesses. So also in health care. There are a lots of different definitions and discussions regarding "what is lean?"
The definition of lean made by Jönköping County Council is that we look closer at the microsystem and try to identify value streams and waste. Lean is about small changes and continuous improvement of health care.
LEAN could consist of 5 principles
- Identify value for the customer. For example Clinical Quality access, safety and satisfaction with services.
- Redesign value flow by reducing waste like overproduction, unnecessary movements, stocks, deficits, transports, waiting, over work and not using creativity and skills amongst staff.
- Create a smooth and effective flow until bottle-necks are eliminated.
- Use pull-techniques – don't act until it is asked for, needed by the customer or the next step in the value chain.
- Continuous improvements. Create a learning system so the work tomorrow will be a bit better than the work today. Standardization of work is crucial because it is impossible to improve a process that is not stable and standardized.
Some useful methods used in the Jönköping County Council; 5S, Value flow mapping, PDSA-wheel (model for improvement), Spaghetti Diagram, waste identification tool, fishbone diagram, A3. Run charts.
- Measurements for better leadership
How do we work with measurements?
To base decisions on facts is of great importance in our County Council and it drives the work with measurements. We work with measurements on macro, meso and micro level. We use models for balanced measurements to be able to capture performance from more than one perspective/dimension. The models we use are Balanced Scorecard (BSC), The Clinical Value Compass and the framework of Triple Aim. The Balanced Scorecard is used in the County Council on macro and meso system level, e.g. health care service area, clinical department and primary care center. The Clinical Value Compass is used on meso and micro system level, e.g. patient processes. The framework of Triple aim is used on the macro level.
We stress the importance to capture data over time and visualize data on dashboards. The challenge is to build a leadership based on improvement and transparency. One starting point is the different perspectives on measurements, research, accountability and improvement. To be able to learn from data it is essential to have improvement perspective and measurements that are done over time with the use of statistical tools. This includes linking measurements and improvement.
What measurements do we use?
- Balanced Scorecard
- Patient Safety Indicators
- Clinical Value Compass in patient processes
Why are Measurements an important aspect of Improvement work?
In the model for improvement measurements it is important to ask the question "How will we know that a change is an improvement?" Measuring over time is the only way to be able to assess improvement work. Good use of measurements gives feedback to the improvement teams and motivates our employees to continue their journey on continuous improvements. It is important to use good statistics tools. The tool run chart and control charts are examples of methods that are implemented in our county.
Measurement for Management (Mäta för att leda)
The program Measurement for Management (Mäta för att leda) has been running over five years and more than 700 managers/leaders within the Swedish Health Care System have attended the program. The program has five themes:
- Balanced measurement
- Measuring in the macro, meso and micro system
- Measuring over time
- Visualize data
- Linking measurement and improvement
The program consists of three seminars so called Learning Seminars, where teams deepen their knowledge about the five themes and work with their infrastructure for measurements. We have included the concept of coaching in the program and each team has a measurement coach that supports the team with statistical skills. The overall aim is to improve the infrastructure for measurements and at the final seminar a dashboard is presented.
The goal for working with care prevention is to avoid that injuries occur during care and to guarantee all patients a safe and equal care. This is done by building a preventive way of work characterized by structure, systematics and transparent results. Jönköping County Council has chosen to develop a preventive way of work primarily within the areas: pressure ulcers, malnutrition and fall injuries. The reason for choosing these specific areas is that they have huge consequences not only financially for the County Council that provides the care, but also and most importantly for the patient. Therefore risk assessments are a key factor to achieve better prevention. By building quality registries where the patients that are most exposed to care injuries, such as for example the elderly and chronically ill, are assessed and registered is a key factor in achieving a safer care. Another way of achieving prevention is to make use of social movements to train and educate people to take care of their health and avoid unnecessary injuries.
Examples of Prevention Offerings:
- Passion for life
"Passion for Life" is a program designed to encourage elderly people, while they are still active, to take responsibility for a healthy life. Social networks are set up within "Life Cafes" where groups come together to learn about the World Health Organization themes of healthy eating, socializing, physical activities and safety
More information: www.lj.se/passionforlivet (In Swedish)
- Senior alert
Senior Alert (SA) is a national quality registry (one of 90 different registries in Sweden) aimed at preventing malnutrition, pressure ulcers and falls in elderly care. With Senior alert, the goal is to develop new preventive working methods that increase the possibility of best possible care regardless of who provides it. Senior alert is a part of the Swedish Association of Local Authorities and Regions' (SALAR) campaign "Better life for sick elderly". The keeper of the Registry is Qulturum, the unit for learning and innovation within Jönköping County Council, Sweden.
More information: www.lj.se/senioralert (In Swedish)
The Primary Care within the County consists of 52 Health Care Centers. 31 are County Council owned and 21 are owned by private actors. According to a law that was introduced in 2010 the County Councils are obliged to enable other actors opportunities to run primary care units. For Jönköping County Council this law caused a big change. The Council went from 35 Health Care Centers of which 2 were private owned to 52 Health Care Centers where 21 were private owned. The Primary Care is run by a set of regulation with a clear mission and a specific system of compensation. A part of the mission is to get today's work done and at the same time improve it. Qulturum is a free resource which means that all units within the County Council no matter who is the owner can take part of the programs and trainings offered by Qulturum. Both private and public owned primary care units can utilize Qulturum in order to increase the competence of achieving the best possible care for the inhabitants in the region. Qulturum has the experience of knowing how a whole system works with action plans and improvement work according to the PDSA (Model of Improvement).
Qulturum, a center of learning and innovation has over the last 10 years developed a special competence in Coaching. We work in a strong relationship with our customers in our support of the improvement work. Our strategic aim is to, together with our customers, emphasize the positive effects of the process or work and, by doing that, to energize and accelerate the good habits and actions.
There are five strong values that we emphasize in our coaching programs:
- The customer has two jobs; one is to perform the daily work and the second one is to improve it. We support doing both jobs in the best possible way.
- We build strong relationships over time and we meet with our customers both physically and at the virtual meeting places
- The world is global and the work and development has to be done locally. We are a bridge in supporting this.
- We are looking for a "positive deviance" and always try to energize the positive sides.
- We collaborate and emphasize the importance of collaboration because we know that it brings best results.
The art of coaching, co-learning and collaboration comes from a systematic approach where four features have to get in place:
- Structural approach
- Processes of quality and innovation
- Relentless search for good measures and tools for collecting the improvements and results
- Cultural understanding of the need of relationships as a search for support of excellence, excellence understood as each individual's attempt to do the best they can.
Co-learning is a concept which implies learning from one another and perceiving your partners as "critical friends".
Collaboration is an art in itself and should be perceived as something you execute when it is possible and needed. Good collaboration amplifies strength of acting together in search for new knowledge and understanding.
Examples of successful coaching where Qulturum has pursued collaboration and co-learning in our programs are
- Passion for life (link to Passion for Life)
- Learning Cafes (Link or description)
- Together (Link to Tillsammans)?
- Esther (Link to Esther)
- Study circles in "Safe care-all the time, everywhere"
Fellowship Qulturum is a program where we invite health care professionals to learn together with us during a longer period of time. As a participant, you will, under six months, follow our work closely and be involved in Jönköping County Council's approach and its center for learning and innovation, Qulturum.
We give you the opportunity to further develop ...
- deep knowledge on quality improvement
- go from words/science into action
- reflection and learning about what brings about real change in culture
- opportunity to build networks
Our fellows are those who…
- want to learn more about the improvements
- are working on learning and innovation in health care
- want to train to coach themselves and others
- have the support from the chief executive to use new experiences and learning in practical everyday work
- The program is set during the first meeting. During the next six months you will be offered to participate in various activities organized by Qulturum (the choice of activities is based on your own needs and interests.
- The program starts with a lunch meeting where you will be given an introduction and you can tell us about your needs and expectations.
- An important part of the Fellowship program is to openly share knowledge and experiences.
- The program is based on "learning by doing" so that you will be expected to actively seek for the knowledge yourself.
- Based on your own areas of interest you will be given the opportunity to deepen understanding and knowledge about different areas of improvement.
- Collaborative learning is the cornerstone of everything we do.
Some examples of the areas that we emphasize:
- What does it mean to develop the value of services for customers in healthcare? How can Toyota's example with their strong customer focus be translated into healthcare?
- To what extend is the performance of the healthcare system in need of improvement?
- How do we know that a change is an improvement? Differences between scientific measurements and measurements to improve.
- Leadership - to develop microsystems and the team concept that brings people together around a shared vision based on need-to act and follow up results and continuous improvements.
- The micro, meso, macro - how do we develop a deeper understanding of the system that we all are part of?
Workshops on the future of Healthcare, facing the challenges and meeting new trends
To face the challenges and to keep the vision "For a good life in an attractive county" alive is our first priority. We put much effort in following the latest trends and even in creating new ones. Workshops with our guests allow us to prepare for the future together. We strongly believe that "two minds are better than one" and we have a deep trust in the power of cooperation. Our workshops are delivered in a true co-learning spirit.
Let's create memories for the future together!
Qulturum is a name we created ourselves. QUL in the name Qulturum stands for Quality, Innovation and Leadership. These elements are interdependent and they need to interplay for a better performance of an organization.
The first letter in Qulturum's name stands for Quality as it is one of Qulturum's most important focus areas. Quality is the business strategy of health care systems in our county and, therefore, it saturates the whole organization.
Quality as a business strategy
The history of Jönköping County Council and its healthcare is over one hundred years old. However, the development of the Quality as Business Strategy in the County Council has taken place during the last two decades and is now a powerful tool for steering and improvement of the healthcare delivered to the county's population.
(The development of Quality as Business Strategy in the County Council of Jönköping, Sweden http://www.lj.se/info_files/infosida31736/historik_version_feb2007.pdf)
Quality as a Business Strategy includes various concepts, philosophies and specific methods which are converted into action and implemented into managing a business and quality improvement within an organization. This strategy can be applied in all types of organizations, in both private and public sector and it has two main goals; one is to enable the organization to produce products and services that will be in demand and the other one is to provide a workplace where all the employees greatly enjoy and take pride of their work.
Focusing on quality enables achieving other goals, such as increased profits and share of market, growth, better educated citizens, cleaner environment, lower cost etc.
There are four important approaches to achieve higher quality:
- Design a new process, product or service
- Redesign an existing process, product or service
- Improve system as a whole
- Share and collaborate with a known improvement and diffuse the innovation
Designing new processes, products or services or redesigning the existing ones doesn't usually cause too much trouble. It is improvement that is much more complex and demands more innovation and creativity. Qulturum's role is to help the organization achieve this goal by facilitating improvement and by sharing and diffusing of innovation.
"The big difference is that we are not only working with quality control, we are improving it".
Göran Henriks, Chief of Learning and Innovation
Improvement and Innovation are other very important components of our organizational strategy. In Jönköping County Council we say that everyone has two jobs; one is to perform your daily work and the other is to improve it. According to W. Edwards Deming (www.deming.org) you need profound knowledge in order to improve your work. Profound Knowledge is a complex term for various theories and sciences that are used to achieve changes that will lead to lasting improvements, development and innovation of businesses and practices. This body of knowledge which is necessary for making improvements contains:
- An appreciation of a system
- Knowledge about variation
- The theory of knowledge
In order to achieve the highest value for the patient both Professional Knowledge and the Improvement/Profound knowledge is needed. Improvements in diagnostics and treatment need to be matched with improved processes and systems in order to reach best possible results. (source: Batalden)
In the health care system improvement knowledge is a joint area of competence of healthcare professionals, patients, economists, planners etc. and the challenge lies in integrating and developing together. It is a shared and continuous effort to make changes that lead to improved patient outcomes, better procedures and better learning.
Improvement is not about a number of successful projects; it is about how you work systematically with improvements to get all processes in the system in motion and show results in a systematic way. In a system based on values, and under the right circumstances, we believe that people want to develop not only themselves but also their activity.
As a center for learning and innovation, Qulturum focus on developing improvement knowledge concerning patients, co-operation, interprofessional teams, management and the design and redesign of healthcare.
The following strategic areas are, by Jönköping County Council, identified as the most important to improve in health care and are thought to increase the value for both patients and the population.
- Learning an innovation (including leading and leadership)
- Access and how we treat our patients with respect and caring
- Prevention and Self-care
- Cooperation and flow
- Clinical improvement
- Patient safety
- Good financies and Reliability
We use a multitude of different methods in our improvement work and the most basic is the Model of Improvement with three questions and the PGSA circle:
The answers to the three questions are: 1) to set goals, 2) to decide what measurements to use and 3) to develop ideas and proposals for improvement and to test them.
Jönköping County Council has 10 000 employees and serves 300 000 inhabitants in the Jönköping region. The Council has got three hospitals; Ryhov County Hospital in Jönköping, the Höglandet Hospital in Eksjö and Nässjö and Värnamo Hospital.
We strive to accommodate the requests from our visitors, but, please, be patient and consider that when it comes to site visits we are dependent on the availability of the clinics. Providing the best service to our care takers is always our number one priority.
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