The Esther approach to healthcare in Sweden: A business case for radical improvement

The County of Jönköping in Southern Sweden with a population of about 330,000 transformed its healthcare system to respond to the bad experience of an elderly patient in the late 1990s and introduced a patient-focused approach to health care. The graph below illustrates the shift from a traditional service provider-focused approach to one centred on the pathway of patients to health care. Read how the 'Esther approach' was developed and what it achieved.

The Esther Network was initiated by the Chief Executive of the Medical Department in Eksjö, Mr. M. Bojestig, in 1997. It was triggered as a result of the experience of an elderly woman patient called Esther with the healthcare system. Esther lived alone and one morning developed breathing difficulties. After seeking advice from her daughter, who did not know what to do, Esther sought medical advice, was then seen by a district nurse and told to visit her GP. The GP said she needed to go to hospital and called an ambulance. After being admitted to emergency care she retold her story to a variety of clinicians at the hospital during a five and a half hour wait. In fact from first seeing the district nurse, Esther saw a total of 36 different people and had to re-explain her story at every point – which was made all the more troublesome by her breathing problem. This process caused Esther to become confused (which could, in a worst case scenario, have resulted in her being mis-diagnosed with dementia). After her long wait, a doctor finally admitted her to a hospital ward and treatment began. In light of this story ‘Esther’ has  become  the generic name  and character used to establish the Esther Network to help focus clinical and social care on the needs, expectations, priorities and fears of people entering the care system. An ‘Esther’ is usually described as an elderly woman (or man!) with one or more chronic conditions, who requires care from a variety of providers.

Looking at this experience from a patient perspective shows that limited value was created from Esther’s interactions before and during her admission to hospital - in spite of the best efforts of healthcare professionals. The episode highlighted significant wastage in the healthcare system because the links in the care-giving chain didn’t fit smoothly together.  Furthermore, Esther’s lack of knowledge of what to do and who to contact when faced with her health issues created a delay in her treatment and added to the workload of the nurses that could have been prevented (Davies, 2012).

Following this event between 1997 and 1999, an analysis of patients’ care journeys was undertaken to identify redundancies and gaps in the current system, and to develop an action plan to reshape the system. This process consisted of over 60 interviews and several workshops with patients, staff, and government officials (Carlsson, 2010). It identified that patients felt that healthcare personnel didn’t have enough time to listen; and that too many people were involved in their care. It was also clear that individual work processes of staff in the care chain didn’t fit together with the work of other colleagues, before or after their patient contact. This lack of coordination could mean, for example, that although a patient’s social worker may have gathered information about their circumstances the patient would also be asked the same questions by their GP, nurse, and so on. This inadequate coordination causes considerable waste, redundancy and, in the worst case, medical errors. 
  
An action plan was developed to redesign its system to avoid past errors and gaps.

The thinking of healthcare providers and planners was therefore reshaped to focus on the aspects of a service that patients, rather than clinicians and managers, most valued – to create ‘patient value’. In order to look at services through the eyes of a patient, providers and planners had to learn:

• what a patient needs or wants;
• what is important for them when they are unwell; and
• what is important for them when they leave hospital.  

Staff discovered that most patients want to receive as much care in their home or as nearby as possible. If they have to go to the hospital, the patient prefers to leave as soon as is feasible, and have their continuing care needs met at home. This understanding led to a key part of the new system seeking to ‘move responsibility to the patient’.
     
The ‘patient charter’ illustrates the new vision of the relationship between professionals and patients which developed in the Esther Network (Wackerberg and Svensson, 2011) – see ‘Who Is The Customer’ below. In addition, there is a direct telephone line for complaints, whereby patients can talk with a person who will write down the complaint and give feedback to the involved partners. This can also lead to improvement meetings with patients and staff where appropriate. Of course, every caregiver and provider makes their own promises in addition to this overall statement.

A simple, but effective way in which the network has tried to prioritise the patient’s wishes has been through the introduction of ‘Quality time for Esther’ sessions. This is personal time, usually a half hour period each week, in a social care environment that the patient uses to focus on activities which they prioritise themselves (often with nursing assistsance). In 2010, 78% of users had made use of this opportunity (Wackerberg and Svensson, 2011).

Also, the Esther Network focuses on the patient’s illness as a ‘journey’ – from illness, to treatment, and finally recovery. By evaluating every interaction with healthcare professionals, from the first contact point to the patient’s recovery, professionals are able to remove unnecessary contact points and improve efficiency. Focusing on the patient journey also creates greater understanding amongst staff of the role of all other actors in the journey. This has improved cooperation between different professionals, who come from different departments and organisations to work together to meet the needs of the patient.

To further enable this action plan meant that organisations within the network improved telephone and email routines to create a speedy and seamless process. An example of this has been that GPs and hospital departments have improved their routines so that the hospital can now admit patients straight to the wards.
 
The Network has also improved contact between patients in nursing homes and their GP through measures such as establishing dedicated physicians at nursing homes, and regular visits by physicians to the homes.

Staff and patient feedback have also resulted in the design of more effective prescription and medication systems. Medicine lists now follow patients through the chain of care. This common list ensures all affected personnel have up-to-date information that helps avoid unnecessary changes to medication – although this process has still not been perfected.

The speed of passing on information has increased through the creation of targets for transmission. Documentation is also tailored to the needs of the next link in the care chain because each receiving care unit defines what they need from the preceding department. This has been further enabled through the improvement of IT systems to create an integrated and standardised system.

A ‘Virtual Competence Centre’ has been created to enable the transfer of knowledge and improvement in the capabilities of practitioners involved in the care chain. In particular, the competence centre has (Project Esther and IBM, no date):

• adapted training to focus on fulfilling the needs of patients and moving efforts towards caring for Esther at home;
• educated personnel about different patient groups’ needs;
• introduced multi-professional teams across Hospital, Primary Care, and Community Care;
• sought to improve the quality of meetings between patients and personnel.  

In 2006, the Competence Centre received 12 million kronor (£1,138,279)  to provide a two-year training programme for members of the healthcare network in systems-thinking, communication, and IT development across the care chain. Following a system-wide survey assessing training needs of health care teams, the training was extended to include (Carlsson, 2010):

• medicine management;
• telephone advice; documentation;
• IT and communications.

Since its creation, over 700 people have participated in training programmes.  An evaluation of the training shows positive results. Staff feel that the project has helped to strengthen team-work, and establish better understanding of the different roles through interdisciplinary learning (Carlsson, 2010).

Also, in 2006 the network established ‘Esther Coaches’ to embed the new approach throughout the network and promote continuous quality improvement. Esther Coaches are members of staff - both clinical and managerial – who have the following tasks (Wackerberg and Svensson, 2011):

• support improvement projects in the frontline – by enabling staff to make the changes they want to see;
• catch improvement ideas and introduce new thinking to improve competencies;
• make the connection between daily work and the improvement of performance;
• inspire and motivate colleagues to improve, and celebrate improvements;
• keep the focus on the patient;
• introduce ‘lean thinking’ – getting the right things in the right place, at the right time, in the right quantities, whilst minimising waste and retaining flexibility – to make workflows smoother;
• securing ‘Quality time for Esther’ to ensure patients can set the agenda.

To enable them to provide this role, coaches receive training on how to analyse problems in health care work and design improvements to address them. To spur innovations, Esther Coaches have to be solution-focused, encourage positive thinking, and be opportunistic. Esther Coaches receive no extra payment for their involvement and, despite being a major commitment; it is considered part of their job. In 2011, 102 members of staff had become Esther Coaches. Table 1 indicates the professions and their place in the network of the coaches as of 2011.

The Esther Network for re-designing patient care has been crucial in delivering improved patients outcomes, whilst delivering resource savings. The success of the project became obvious very early. A total system wide redesign took place, from 2000-2001 onwards  to focus energy and funds on caring for the patient at home. This resulted in a 20% reduction in hospital admissions. In 2003, the Esther Network won the ‘GotaPriset, Swedish national award for quality improvement. This was because the project exhibited outcomes such as:

• Hospital admissions fell from approximately 9,300 in 1998 to an estimated 7,300 in 2003.
• Hospital days for heart failure patients decreased from approximately 3,500 in 1998 to 2,500 in 2000.
• Waiting times for referral appointments with neurologists decreased from 85 days in 2000 to 14 days in 2003.
• Waiting times for referral appointments with gastroenterologists fell from 48 days in 2000 to 14 days in 2003.
• The number of unnecessary days in hospital decreased from 1113 in 1999 to 62 in 2011. 

Unnecessary days in hospital:

The measurement here is the amount of days the patient remains still in hospital although they no longer have a medical need for specialist care. This can occur for example if the homecare service or primary care  does not have the capacity to look after the patient at home.

Esther resulted in the following changes: