Judson Howe
So explain to me the Swedish mentality that somehow thinks it's enjoyable to put skintight outfits on and to — in the winter, the dead of winter — ski for 75 kilometers. What makes a society think that that's appropriate?
Göran Henriks
I have to give you a little longer answer than maybe you expect. You know, Sweden was the poorest country in Europe up until 1870. And at that time, one third of all the population left to the States, to America, to the beautiful country. And they all knew that it was not because of the beautiful country they left. They left because the families couldn't afford to have them at home and there were no work. So they were more or less thrown out of the country. Up until then, Swedes were very much farmers, living in the forests. And I think that we have kept that kind of approach to life. So Swedish people love to go outside and go into the forest, go to the lakes, fishing, being in the green context. And I think it's connected to that also an approach of being healthy. And for over 100 years now, we have had a celebration of our king that lived 500 years ago, that escaped from the Danish army up north. And the tale or the story is that it was 950 kilometers.
Judson Howe
Oh, wow.
Göran Henriks
To remember this king's efforts to make Sweden to a whole country and throw out the enemies, we do this ski race every year. And today I think it's about 30,000 the day of the big races, but it's a whole week. So it starts the Sunday before with having a women’s Vasa race and that's half the distance. And then there is something that is called the open trail so during from Monday to Saturday you can go this 950 kilometers when you like to go it. And then they also have a night Vasa, and then you have to go in pairs and there is a rope between the two skiers and then they have lamps on their heads and that has become a competitive race so now they race —
Judson Howe
At nighttime. With ropes tying them together with headlamps on.
Göran Henriks
It’s a big thing in Sweden. But this is only one of the things you should do if you should be a real Swede. You should also swim about three kilometers in a river that has about six degrees Celsius in the water and if you do that you become nearly a real Swede. The third thing is –
Judson Howe
You have a wetsuit on for that, right?
Göran Henriks
Nowadays but not historically. Then they took — I'm not sure of the English word — you know that black, it's not oil but —
Judson Howe
Whale fat? What's the Swedish word?
Göran Henriks
Tjära
Judson Howe
Okay, we'll look it up.
Göran Henriks
And then the third race you do is you go by bicycle around the lake where I live, Vättern, and that's 300 kilometers. And for the best ones it goes in five or six hours, but for most of the people it takes between 12 and 20 hours. And that's a big festival also, this race.
Judson Howe
Have you ever done these?
Göran Henriks
No, I have never done any of those.
Judson Howe
Okay. But in your community these are common?
Göran Henriks
Yeah, very common.
Judson Howe
What are your fitness activities?
Göran Henriks
No, but I have run many half marathons.
Judson Howe
Okay
Göran Henriks
I do skiing too, but...
Judson Howe
Okay. But you don't like to tie yourself up in ropes at night.
Göran Henriks
No, well, my life has not given me the opportunity, and I haven't taken it.
Judson Howe
Great. Göran, every visionary has that wake-up call moment. What was yours?
Göran Henriks
Well, I need to give a little history. I have a background as a child psychologist. I have been a sports teacher connected to my basketball work. So I was national coach in basketball for 20 years. And then I have a master’s degree in finance. And when you scramble that and let the things go out, the knowledge platform becomes quality and performance in different areas. So that's my platform. And then I came to where I live asked to work as a child psychologist and at the same time start a college in basketball. I worked both full-time as child psychologist and then started this college. They found quite early that I could help out in other things, the system, the organization. So they asked me to come to workplaces where conflicts were in the way, and they asked me to help groups to become teams and such things. They also asked me to involve myself in leadership thinking, so I became responsible for leadership development in the healthcare system where I work. And it was a very special situation because we had leadership development for the chief of wards, and then we had leadership development for chief of departments, and then we had leadership development for the CEOs. And when I talked with the nurses that mostly were the chief of the wards, they were complaining that their life was terrible and it was so hard. And — now we are back to 1990, 1992 — and that their chief of department never met them and they didn't listen. So then I went to the program for the chief of departments, and when I asked them why the performance looked not as good as it could, they said, well, the problem is that I have bad chief of wards. And in Sweden, we have laws that say that you can't throw out someone from their work without a deep or big reason. So they were saying that we can't get better results because I didn't employ that chief of the ward. And when I then met the CEOs, their main interest was not the work. Their main interest was maybe the stock market or how the money flows in Sweden with taxes and so on, and had nearly no idea of how to manage the daily work. So I found that there were logic bubbles between each layer or level. And I asked myself, should I live in this kind of Kafka world or should I try to change it? And I guess I got some good colleagues and they convinced me that let's try to do something.
Judson Howe
Give me a specific story where you were like, I want to challenge this.
Göran Henriks
I earlier became a secretary — I'm not sure if that is the best English word — but I was the administrative resource for the medical quality group of the system, and I had a professor in surgery and medicine and infection disease and the CEO in that group, and then I was sitting there with a paper and pen and should summarize what they were talking about because the system CEO had asked them to, now we must work with quality. But the first year was quite boring because no one had any quality issues, so they didn't know what we should do. But we met three times that year and just discussed. Then the second year, the professor in surgery came up to me and said, Göran, I have something we need to look at, but I don't know how to do it. And I think that one of the hospitals are not doing that well in colon cancer. And I was quite nervous because I had no experience really to work with the physicians about the performance in that narrow situation, so I said let's talk with the group and see how we should design an approach. And you know we had two meetings and we couldn't find consensus of how to do it. It went another nine months before we finally found the idea and that was to bring in a young surgeon from a university hospital from Lund down south to us and ask him to read the patient records from the three hospitals two years back. And then we asked him to, well, we need a manual or a guideline. So it took another four months before he came back with that. And then they said, yes, that looks good. And he started to read the patient records then. And after another 9 to 12 months, he came back and said that I have found a problem.
Judson Howe
What was that?
Göran Henriks
That it was true, one of the hospitals were not performing that well. And then it became very quiet in the room, and no one really wanted to hear that result. So we had to stop the meeting and go home and think. But four months later we met again and then we came to consensus that we should invite all the surgeons to the most beautiful conference center we had, and we should start Thursday morning and tell them that they couldn't go home before they had found an approach to this. It was like a conclave, you know. But I had my professors behind me, so it worked okay. And the surgeons, of course, had deep discussions if the results that this young surgeon from Lund came up with was true or not. But they admitted that we needed to find out this deeper. So then we decided that two surgeons from Hospital A should go to Hospital B, and then two from Hospital B to Hospital C, and then two from Hospital C to Hospital A. And we asked them to map the process that they saw, and nearly with pen and paper make drawings of how they worked.
Judson Howe
Wow. Like the spaghetti diagrams?
Göran Henriks
Yeah, and things like that. Now what we found then was the key issues at that hospital, and we had meetings then with all three hospitals but in a tone that all three hospitals needed now to look into their processes. We didn't want to say that C you have to change, so all three must go through the process. Why I tell this story is because we stopped there and continued to live as usual and we never checked if they really made any change. So then 2010 I became the chairman of our university region's cancer organization.
Judson Howe
How many? That's 18 years? Or how many years?
Göran Henriks
And we had the opportunity then to put in a new quality register with 27 different indicators that follows the patient from the first visit to going home into rehabilitation. And when we got the first results in 2012, I looked into the data and saw that the same situation still exists.
Judson Howe
It hadn't improved in 18 years? Why was that?
Göran Henriks
Well, I can't answer that question because that's how healthcare quite often works. That the trust to the education and license of being a physician or nurse are the safety system quite often. Now it has changed, because since 2010 we have had something we call clinical program groups. So twice a year, all clinical groups come to a meeting with the top management of the system, and they have to report what they tried to achieve in two areas and how well they are doing compared to the rest of the country. That is the main issue. We do it twice a year, so the meeting always starts with what have they achieved based on what they said the last time. Today we have the best clinical results in Sweden in our system.
Judson Howe
And your system is Jönköping?
Göran Henriks
Jönköping. And the strongest finance. And we do not measure every day's cost, we measure every day's clinical performance.
Judson Howe
In addition to the cost? or do you focus primarily?
Göran Henriks
Well, everybody has a budget. So they are aware of the situation that if they use 110 one day, they need to use 95 for the next two days. But that's it. We have no pressure on the cost except for a responsibility.
Judson Howe
Budgetary constraints.
Göran Henriks
And we are so sure that it is how well we are doing clinically that makes us rich. Because every time we hit the target and reduce the variation of things, we save money because there is no reuse of things.
Judson Howe
You know the American system probably better than many of us know the Swedish system. An assumption I'm making. If you were to explain to a U.S. healthcare executive—
Göran Henriks
How it works?
Judson Howe
—the biggest head-scratcher, like the difference between the two, like the most absurd difference between the two systems, what would that be?
Göran Henriks
I need to explain a little how the Swedish public system works. So I pay 23 to 25 percent tax to the municipality on my salary. Then I pay another 10 percent of my salary to the region. And then if you have a high income, 10% of the people that have the highest income, they also pay from their income to the state, but 90% do not. So the average tax level is 33% in Sweden out of your salary. Now, you pay tax VAT also and then you pay —
Judson Howe
It's like a sales tax on consumption.
Göran Henriks
Those money goes to the state. Now, the people that pay tax to the region are the people that are employed. So between 20 and 65 roughly, you pay tax to the region and that goes to healthcare. So in a way we know every year how much money we will have because we know the income from the population in that. Now I will complicate it a little because we have what we call a Robin Hood system also. So we have an agreement that we should equalize the money between the regions and also the municipalities based on social care indexes —
Judson Howe
Social care index.
Göran Henriks
Yeah, so if you have a poor population or a lot of elderly people and so on and you have not strong incomes in your county then you get money. But if you have young population, healthy population with high salary, then you pay. So all 21 regions starts with the same amount of money based on the population situation. So Stockholm that is the richest region, they are always angry because they have the youngest population and the highest salary so they have to pay to others. But that is fair because a lot of people also move to Stockholm and the elderly population stays in the different rural regions. So anyway, this means that there is a competition between the regions, so to say that everybody has the same amount of money every year. Now the regions have by law the responsibility to distribute the service to the population.
Judson Howe
OK. How much flexibility do they have?
Göran Henriks
They don't have to have any hospitals or they don't have to have any care centers. It is a regional decision how the design of that distribution should look like.
Judson Howe
Wow. So a lot of autonomy.
Göran Henriks
A lot of autonomy and there is a political board on the municipality level, the regional level and the state level. So it's very easy to compare how well the different management systems work based on the knowledge that we start with the same amount of money. Now, since it's a tax that goes into the region, the region becomes more or less like an insurance company. So, it's as it is in the United States, people that are employed pay to an insurance that pays the money, where the money goes to childcare up to 20 and all the elderly care too. So that money is used for the whole population, but it comes only from a special part of the population, you can say.
Judson Howe
So when you're looking at the American system, what do you think is the most absurd piece of our delivery system?
Göran Henriks
I think that it's not if it's private or public. I think it's the incentives that you get paid per unit you do. That takes the responsibility of the finances away from the floor, so the—
Judson Howe
Explain what you mean by unit real quick for me. Like a widget, like a …?
Göran Henriks
Yeah well everything, every action you do —
Judson Howe
There's a monetization to it.
Göran Henriks
Yeah, and it's impossible to have it like that because all people are different, and you have to do different things to different people and if you start to get payment for everything then you find things to do. But since we have a limitation of how much money we have for this, we robber the system by doing extra things in a way. And the insurance companies here are like our regions in one way because they also have a limit of how much money they have. The problem now is that the ownership of the system is separated here. So insurance companies buy from hospitals that are owned by others. But in Sweden we have the ownership —
Judson Howe
I'm going to repeat back to you what I think I hear you saying. Just correct me where I'm wrong. So we have the beautiful taxation system you talked about. Complex, there's some tension between it. It's not a perfect system.
Göran Henriks
Not everyone loves it.
Judson Howe
But within there, there's the regions of which your Jönköping has significant autonomy to take that pool of resources and care for their population.
Göran Henriks
Exactly.
Judson Howe
They can then decide how to structure the delivery system.
Göran Henriks
How the delivery system should work, yes.
Judson Howe
Hospitals, clinics, specialty, primary care. But the region has the incentivization to provide for an aggregate outcome for that population.
Göran Henriks
Yeah, and no one wants to pay higher taxes. So our success is, of course, if we could keep the costs down so we don't have to raise the tax. And it's the same in the private situation. No one wants to pay higher insurance premiums.
Judson Howe
So if Jönköping effectively delivers a given level of care at less cost, where does that margin go?
Göran Henriks
Back to our system.
Judson Howe
To the region for other, to build schools and transportation?
Göran Henriks
No. Well, in the future, yes, but right now it goes back. So, for example, our region do not have any bank loans, and we have built three new hospital buildings without any bank loans because we have so strong economy that we can pay the construction work over time and still deliver.
Judson Howe
What is your role today inside of that system?
Göran Henriks
Well, today I'm an advisor.
Judson Howe
How about 10 years ago?
Göran Henriks
Well, I have been chief executive for learning and innovation for 29 years.
Judson Howe
It sounds a lot like what in America some would call value-based health care.
Göran Henriks
It is. Even though the value-based healthcare here started with the reaction of New Public Management and Michael Porter and I think it was a woman named Teisberg that tried to find a new construction of New Public Management, but I think they got lost a little in the solution. So the value-based healthcare here are still a type of New Public Management. And we have different regions in Sweden that have tested the same thing. Now I think the biggest issue is where you permit that the sub-optimation of resources should come. So in my system we have taken away CEOs from the houses. So we don't have hospital CEOs.
Judson Howe
Where are they?
Göran Henriks
Well, we don't have any. So we have CEOs of the clinical processes. So we have a CEO—
Judson Howe
I'm picturing like this horizontal –
Göran Henriks
So we have a CEO for three hospitals of medical processes and the CEO for surgical processes at three hospitals, and the CEO for psychiatry and rehabilitation, three hospitals.
Judson Howe
Who's waking up every day thinking about the cleanliness of the hospital facilities, make sure the lights are on, opening the doors, philosophically? Who's doing that work?
Göran Henriks
Well, that is the service system. So we have a service company that we own that runs the facilities and then we have another service system that looks after medical technology, but they are just service systems.
Judson Howe
Who do the physicians work for?
Göran Henriks
They are employed within the healthcare system.
Judson Howe
These horizontals — my word —
Göran Henriks
Yeah, but then the horizontals are within the whole system in the region. So the doctors are employed at different departments. So we still in some areas have the definition of a department, so we have a department of medicine, a department of surgery, a department of infection disease, and so on, but they work over three hospitals.
Judson Howe
I’m really resonating with this at the population level, but how about at an individual level? My grandmother might have an issue that I want the region to pay attention to urgently based upon my emotional attachment to my grandmother. How would I go about advocating for her to get timely diagnostics and intervention inside of this public system?
Göran Henriks
Well, if it works properly you go to the care center and the primary care doctor, the GP, and have a discussion, dialogue with you and your mother and —
Judson Howe
And let's say they refer her for an MRI. How long is that going to take her to get an MRI?
Göran Henriks
Well it's a good question. Because in my system they will have it within 24 hours
Judson Howe
What if we were in Stockholm?
Göran Henriks
Well then it's tougher.
Judson Howe
Within 24 hours.
Göran Henriks
If it's needed directly. I mean, there is also, of course, a segmentation based on the —
Judson Howe
Like a triage or a prioritization. How is that? Expound on that. How is that performed?
Göran Henriks
The simple answer is that there is a guideline that the physician, the doctor follows. But since 10 years, we now have also, I don't know if you know Brent James and Intermountain, but Intermountain Healthcare System are well known to have a theory of how to increase the effectiveness in clinical processes. And we have now made that thinking into a national system. So today all clinical programs are developed on a national level and then the university level — that is, clusters of regions — have the duty to look after so those clinical guidelines are used on the local level. And that has reduced the burden of making local solutions on everything. So we are quite centralized in our standards of how to work.
Judson Howe
How do your physicians or maybe more broadly clinicians react to that amount of centralization?
Göran Henriks
Well, from the beginning there were anxiety about this.
Judson Howe
When was the beginning in your mind on this?
Göran Henriks
2014, 2015. But, when you understand how to use it, there is always a risk because they drive costs sometimes and that causes tension. But most of the time they really like it because then if they can't follow it, they are asked to do notes of why they do not follow the standard. And that is a very good learning opportunity. And 80% of the time you can follow your guideline and that ensures patient safety.
Judson Howe
Do you review those exception-based lists regularly?
Göran Henriks
Yes, yeah.
Judson Howe
Do they ever turn into modifications of the standard?
Göran Henriks
Absolutely, so then there are different networks, how to feedback loops for that.
Judson Howe
You write a lot about co-production.
Göran Henriks
Yes.
Judson Howe
Over the past 20-30 years, that patients aren't just recipients but co-creators of their care. How did you bring this philosophy from theory into reality in your region of Sweden?
Göran Henriks
Well, it started '95, '96, or maybe '92 to '94.
Judson Howe
What happened then?
Göran Henriks
Sweden was bankrupt and our money just flowed out of the country, and we had to rewrite our budget four times those three years, and the trust in the finances were gone.
Judson Howe
Nationally?
Göran Henriks
And regionally. Because our bank system didn't insure the money or there were no blockers that stopped the flow. So it was really problematic. So we decided to see if we could get rid of the budget and instead use something we found that was called Malcolm Baldrige, and that is then a self-evaluation system of how your aims and ideas are connected to values, and if you're acting based on your aims and values.
Judson Howe
Okay. So it's almost like an integrity check.
Göran Henriks
In one way, but it also develops system thinking because you need to coordinate all the different components that is important in management. So you can't have education that do not look into how well things work. So education cannot be something living for itself. Or you must start with a customer view, because if you don't have processes that is connected with the needs, then it doesn't work. We started to try to explore how to do this and at the same time one of our three hospitals decided to have a big project that they named the Future Hospital. A colleague then to me, Mats Bojestig, was a young physician that got the project leader role at the Department of Medicine. And at that time this department had over-crowded emergency room. They had something that they called Acute Medicine ward. So that was a kind of blocker between the department and the emergency room. So it was meant to be like a 12-hour to 24-hour short stay.
Judson Howe
Okay, a short stay.
Göran Henriks
But it seems to be more than a short stay, and then the wards were overcrowded with patients. And he became the chief of that department. And he was the youngest senior doctor there. So he asked me to come and help him because his older doctors were very nice but they were a little conservative, afraid for change. So I was then studying Edward de Bono, and Edward de Bono is a professor in creativity, and he had a tool or a method that he called po, provocation. So we met with this group of doctors and asked them how can we get an approach to all these access issues that we have, and we didn't really become constructive in this. And they thought that I was young and I didn't understand.
Judson Howe
Were they right?
Göran Henriks
I was at least young. But I felt in my body that we needed really to do something extra. So the second time we met — they did let me in a second time — I came and said to them, Let's close the emergency room.
Judson Howe
That was your idea? How was that received?
Göran Henriks
Well, that I was stupid. But I thought that maybe we could go upstream a little and understand better how the different processes looked and maybe we could have the patients go directly to the wards instead of sitting there in the emergency.
Judson Howe
From some sort of upstream access point, direct admit to a ward?
Göran Henriks
Exactly. Then we met a Norwegian CEO from a child hospital in Oslo, and she had been employed by IBM, the computer company. And they had worked a lot with something they called business process re-engineering. So then Mats and I translated that to healthcare process re-engineering and we took that theory — it's a kind of a total quality management method — and changed the language.
Judson Howe
What did you discover as you were doing that?
Göran Henriks
That the key thing is radical customization.
Judson Howe
Radical customization. What does that mean?
Göran Henriks
Yeah, exactly. So then we started to think more about how is it to be frailty elderly, live in a small city, haven't slept for three nights because the body is so swollen, the heart is not working properly. And we found that we should name that woman Esther.
Judson Howe
A generic name for this archetype of a patient, community member?
Göran Henriks
Yes. So then we thought about how was it with our grandmother and grandfather. Well, they called their son or daughter. In our story, it's the daughter that comes home during the coffee break from work and finds her mother in a terrible condition. She says, we have to call the home nurse, district nurse. And the district nurse comes home and finds Esther there and the daughter and says, I'm sorry, I cannot help. We have to call an ambulance. They call an ambulance that drives to the city's care center. The waiting room is totally overcrowded. Esther sits there on a tree chair and the GP that Esther has comes up to Esther and asks her, what are you doing here, Esther? Oh, I feel so bad. Do you have an appointment? No. Well, I have no time for you today, the doctor says, of course. But I try. We have to take some laboratory tests and you can come in to me during lunch. So now it's one o'clock and the doctor meets Esther and looks at the results and says, I think it's better that you go to the hospital in the city nearby and they have to look at you. So now it's 1 30 and they call for an ambulance, but she is not emergency and acute so she has to wait another 90 to 120 minutes. The ambulance takes her to the emergency room at the hospital, it's now 4 30. It's totally overcrowded. There's no chair for Esther. So she has to sit there and at 5 45 a nurse finds her and says we have to change the day team to the night team and then someone will come and look at you. So at 6 30 a young physician comes and look at Esther and says I have to take some laboratory tests. They take some laboratory tests. At 8 00 the doctor comes back and says I'm not sure, I have to call my senior doctor. They call the senior doctor and the doctor comes back, you have to stay overnight. And Esther, she then are transported up to a ward. The ward's rooms are totally full, so they arrange a bed in the corridor. An assistant nurse comes up at 9.30 to Esther and asks, have you eaten anything? No, I haven't eaten anything because they have told me that I shouldn't eat if they needed to do something. So she goes to the canteen and finds two American white bread with plastic cheese and a glass of milk.
Judson Howe
Yeah, plastic cheese and Wonder Bread —
Göran Henriks
And says to Esther, this is what I have. This day, we found that Esther met 36 new people. And she meets maybe five new people a year. And in this condition. We started to find out how many Esthers did we have. And we saw that it was too many. So we closed one ward at a time, one week, and had 50 people every week walk Esther's process.
Judson Howe
So you took people off the ward?
Göran Henriks
Yes.
Judson Howe
And you made them experience the archetype’s experience?
Göran Henriks
Now we are back ‘96, ‘97. We were still young then. Then after a month, when they had done this, we found 11 big issues that we needed to change.
Judson Howe
So those people that had done the empathetic walk they came up with these things.
Göran Henriks
They listed gaps, shortcomings, problems they saw. We summarized that together and found 11 different areas of change. So one of the most important thing was that we viewed our system from inside out. So we found that we needed to collaborate with the municipalities in completely new ways, with the pharmacy in completely new ways, with the primary care centers in a completely new way. So we started to process re-engineer our work based on the idea that we were one system, all the different entities.
Judson Howe
Tell me about a roadblock that you had in that re-engineering process. Who was the most resistant?
Göran Henriks
I think it was the people inside the Department of Medicine.
Judson Howe
The ward itself?
Göran Henriks
Yeah, I think so.
Judson Howe
Why do you think that was true?
Göran Henriks
Well, they were challenged with changing their work patterns. We implemented the idea that we had both a doctor and a nurse to be leaders of each ward. So we had a pair leadership, and that was not liked by the unions and the top management because there should be one chief of everything. We gave all the doctors at that time, I'm not sure if I remember the technique, but we had not mobiles, but we have small, they were like matches with signals that came in, so if someone called you —
Judson Howe
Beepers?
Göran Henriks
Beepers! So all the municipality nurses were allowed to call the right specialist whenever they needed. And what we found then was that the trust that they built with the home nurses reduced the emergency room immediately. So quite often their dialogue ended up in, let's wait another 20 hours before we take a decision if the patient should come in. And that trust building reduced the pressure on the emergency room.
Judson Howe
I mean, I'm not surprised, but I want to key in on that word trust. How important is trust in the medical delivery system?
Göran Henriks
It's one of the most important things. You know, healthcare is — I have to say two things. It is an anxiety industry. So reducing anxiety. And trust is the main way of doing that.
Judson Howe
I'm asking myself, is trust the opposite of anxiety? I don't know that it is.
Göran Henriks
No, I don't know if it is. But it is an anxiety industry. Risk minimization. What do you say? Minimate the risk is the key way of working all the time before you take a decision. Because it's about life. And you want to be very sure before you do something that is not known.
Judson Howe
Before we go on, well, go ahead.
Göran Henriks
I have one more.
Judson Howe
Give me the other one.
Göran Henriks
The other one is that we think it is a medical science, but medical science — and now I will say something that maybe not everybody agree on — is a part of a social science.
Judson Howe
Medical science is a subset or a part of social science.
Göran Henriks
Yeah, I didn't say subset. I say it's a part, because most of the things that happen in medicine have social implications. And it comes down to understand people and understand how not telling people what they should do. It is to understand how can I help you to understand what you should do yourself.
Judson Howe
I mean, that's changing delivery on its head altogether. One of our other guests had talked about health-seeking behavior. How do we promote health-seeking in the individual? I hear you saying something similar.
Göran Henriks
Yeah, seeking for me is maybe no idea thing, but our work in healthcare is to help people to self-help.
Judson Howe
I see. How do we do that better?
Göran Henriks
If we don't talk about the 20% of acute care, but the chronic care is how do we help people to find out what works for them?
Judson Howe
What's the answer? How do we do that? What have you discovered in your career?
Göran Henriks
Trust is of course one thing. You asked me about co-production so we are coming to that now.
Judson Howe
Let’s go to co-production. Is this co-production?
Göran Henriks
This is co-production.
Judson Howe
What does that mean?
Göran Henriks
Well, I don't like the word production.
Judson Howe
what do you like?
Göran Henriks
I think that's the American way of —
Judson Howe
I want to call it what Göran wants to call it.
Göran Henriks
No, I think it's a question of much more co-learning.
Judson Howe
I've seen co-design.
Göran Henriks
Co-design, yes, but I think co-learning.
Judson Howe
Co-learning, because both parties are learning.
Göran Henriks
Yeah. But in the science of medicine, that's too soft. Learning is not a science in that way. But I think we have to remember that everything we decide has a social implication.
Judson Howe
If you were running an academic medical school, how would you revamp the curriculum of physicians to align with what you're teaching me right here?
Göran Henriks
I think that it has to start with meeting the reality where it is.
Judson Howe
Meeting the reality. Whose reality?
Göran Henriks
People's reality, that I will be part of my whole life.
Judson Howe
How do we do that?
Göran Henriks
Well, we try sometimes to change the curriculum through having doctors and nurses very early be out in elderly homes and so on, but I think we have to do that much more serious. So we learn to see in what circumstances people live and should practice the advices we give.
Judson Howe
Before we go on, I want to ask you, I think we just need to establish, where does Sweden rank internationally on healthcare outcomes and cost? And if you have a stat for Jönköping, that's fine too. I want to know the, we've listened, we've valued this, but what results are you getting, both outcomes and at what cost?
Göran Henriks
Well, you know, you can look at this in many different ways. So, but I like to look at it, but it's how active are you after 65?
Judson Howe
Okay. That's a value. That's a societal value.
Göran Henriks
Yeah, and how many years of active life do you have after you end your work?
Judson Howe
In Jönköping, how many active years does one have after 65?
Göran Henriks
In Sweden we are leading that measure in the world.
Judson Howe
Why do you choose that metric?
Göran Henriks
Because I think people want to be free. People want to take care of themselves. No one wants to depend on others. You want to take care of yourself. You don’t want to go to hospital. You don’t want to have a doctor. You want to take care of yourself. So if I can stay active longer, I'm also free to take my decisions.
Judson Howe
That's beautiful.
Göran Henriks
Then there are, when you go into clinical results, there are areas that Sweden are very good, but the technology-driven care now brings specialization to a new level. So then there are, for example, in cancer treatment, fantastic places here in the United States — MD Anderson — that has technology that no one else can afford, and so they have results in certain diagnosis in cancer that is fantastic, that we have very hard to compare with, but we learn from those places. I'm not sure that the results, those kind of results, they are from inside out. We should look at the population.
Judson Howe
You also write a lot about complex adaptive systems, and that's actually a new concept for me. What is a complex adaptive system?
Göran Henriks
Science do not have consensus of what I now say, but complicated things can be solved with mathematic formulas. But complex things usually cannot be understood with mathematic formulas. They seem to be random, but they are quite often logically based in how the system looks and we percept them as complex. So what we try to do with profound knowledge of improvement is to reduce the risk that it should become complex by looking into data in different ways and standardize our processes and so on. That is to reduce the risk that we —
Judson Howe
Before it becomes complex, keep it simple. Is that correct?
Göran Henriks
Yes, yeah and the most — this is a risk in this but by categorizing things we reduce the complexity also, but in the same time we build then also walls, so you need senior leadership.
Judson Howe
The risk, the risk is wall building of those categories. The risk of categorization is wall building.
Göran Henriks
At the same time they are needed because if it's very complicated you have to slow down a little so you understand how to be in charge of that complicated situation.
Judson Howe
How do we apply that to healthcare?
Göran Henriks
In basketball we have an idea of this and let me talk about that first. An Italian coach that were here actually coaching the Dallas Mavericks. Now I lost his name because I live in a different world right now. But anyway, he talked about Festina Lente.
Judson Howe
Say that again.
Göran Henriks
Festina Lente. And it's piano terms. So it is when you should play fast, but it should sound slow. And in care, where so many things happens at the same time, you have to make rules so you can be quick but it looks slow because it seems that you have it under control.
Judson Howe
To help to help us visualize that go back to the basketball. So you're coaching a basketball game. How does Festina Lente look like on the basketball court?
Göran Henriks
Behind what's happening, there are simple rules. So the players have a playbook with different rules that defines how they should act depending on what situations that happens. Now, then they practice that a lot. So it looks spontaneous.
Judson Howe
Got it.
Göran Henriks
And when they are really actors and professional, they can even do something fun based on that. But most of the things are extremely standardized that happens.
Judson Howe
Is this like, I don't play a lot of basketball.
Göran Henriks
No?
Judson Howe
Sadly, sorry. But I remember a little bit when I was trying to play in elementary school. You don't want to let a guy come over the top of you towards the key, right? You want to force them down towards the baseline. That's like, is that kind of the rule of what you're talking about?
Göran Henriks
That's a defensive idea and the rule or a principle.
Judson Howe
And that's an example of …
Göran Henriks
Yeah, because the other four players, they act on that before it happens because they trust that the defensive player that stops then the dribbling to the middle. They are then, in the head, a step ahead. And that's the secret also in care, to organize your work so you are kind of a step ahead. But the only way to reach that is to have everything organized.
Judson Howe
So do we need to have more practices as care teams?
Göran Henriks
Well, it reduces a little the individuality. So it's not that easy always, because some people think that it is an individual sport — care. But it isn't, most of the time.
Judson Howe
Yeah. Are we saying it's a team sport?
Göran Henriks
It's very, very demanding that you act in certain ways in certain situations. And last night I talked with a pediatrician and she told me about her chaotic work and how she was totally consumed of four or five things that happens all the time during her day at work. And we started to discuss, are there any place to zoom out and zoom in again to discuss this chaotic situation? And she said, no, there is no place for this. But this is very dangerous because the only one who can change that are the physicians themselves, the actors. And it's the same thing in basketball. The coach cannot change when the game happens. You can in practice help out, but in the games it goes so quick that you have to let the players read the game and solve it.
Judson Howe
~~I~~'m hearing you say that the coach has a lot a lot of control over practice but in the game, it's game time. But how do we go about creating the practice concept inside of the practice of medicine today?
Göran Henriks
I think it's very important that you have meeting places organized from the daily huddle to weekly meetings where you can zoom out, and monthly meetings and so on. So the way you structure the meeting places are the key to reach effectiveness.
Judson Howe
Do you have any secrets on how to best structure those meetings in your experience?
Göran Henriks
I think my experience is that we need to develop leadership functions and roles that orchestra the meetings so there are places for zooming out. And that takes a different kind of leadership programs than most systems have and we had historically, where you go away and talk about personal development and maybe business ideas. The leadership programs has to be inside the system all the time. So in my system, we have five meetings a year with 550 leaders in different groups.
Judson Howe
Why five? That's an odd number.
Göran Henriks
550 leaders we have.
Judson Howe
But you said five meetings a year, right?
Göran Henriks
Yeah, five meetings a year.
Judson Howe
So not every other month.
Göran Henriks
No, but in Sweden we have vacation.
Judson Howe
Okay. So it would have been six times a year, but you took one away.
Göran Henriks
Yeah in America it would have been six but —
Judson Howe
Eight!
Göran Henriks
But you, because you don't know what the vacation is. So it's five times, and then they meet not based on the process they work in, based on more random grouping. And they are 10 to 12, and they have a structured protocol or kind of idea of what they should talk about, and it's always based on the strategic challenges of the system. So then the leadership development becomes the way to perform even better. And it's the same thing with coach education. So historically, you know, when we had coach clinics and then the coaches traveled somewhere and had an NBA coach or a college coach or something, and they were talking on how good they were. But then when you came home, the space between how that life was and your life was so big that — So when you start to look at coaching as an academic development, then you need to have — It's like when you educate doctors, the mentorship is the key thing. And it's the same thing with leadership, the mentorship is the key, so you need to have it based on what's happening every day.
Judson Howe
in Jönköping is there formal mentorship, like a one-on-one structure? or how does that?
Göran Henriks
Yeah, we have that, but we also then build in the mentorship in those groups so they help each other.
Judson Howe
So both group mentorship and intentional one-on-one mentorship as well. You recently wrote about seven rules for leaders. It echoed a lot like Don Berwick's eight principles for health, but Don Berwick's number eight had eight of them, and number eight was “never lose focus on the patient ‘. If there's echoes between the two, where did the focus on the patient go into your seven rules for leaders?
Göran Henriks
Our first rule was shared purpose, and I think Don's eighth rule should have been first. Because our business is purpose-driven and it always has to be in focus, and I think my example with Esther has shown that. But we never talked really about our acceleration of co-production. It came through patients that showed us that they were much better to lead the ideas around co-production than the professionals were. So we had something we called self-dialysis. We had a (patient named) Christian that lost his second kidney and came up to Britt-Marie the nurse and said that I want to die, I hate dialysis, and Britt Marie found Christian in a very bad mental condition and tried to support him to start the dialysis and he did, after, well, his body showed that it was a must. So he came up to Britt-Marie, Christian, and said, I want to do it myself. And Britt-Marie was clever enough to say, let's try. But they couldn't do that in an open, transparent situation, so they hid this practice. But after some weeks, Christian could come to the ward, pick the equipment, put it into the machine, start the machine, control the machine's speed, and take the different equipments out of the machine, clean it, throw it where it should be thrown, and go home. So he took care of the whole process. Then another patient came up, Patrick, and Christian and Britt-Marie helped Patrick to do it. And then a 70-year-old woman came up, and Christian and Patrick learned her to do it. And after just six months, we had 18 patients that made the process from A to Z. And what we found was a completely different result. We saw that we had no care-related infections any longer with these patients. We saw that we reduced the need of nurses with 20%. And we saw suddenly 18 patients that got their work to get back. Or they could work half-time at least. Those 18 patients had lived on state insurance money because the dialysis were between 8 and 4 when the professionals wanted to work but they came at five o'clock in the morning or started the dialysis at six, seven in the evening so they changed their life. Now here and also in Sweden we try to promote home dialysis, but most people live in smaller apartments, two, three rooms and they hate to have their homes to become hospitals.
Judson Howe
Interesting. They want to segregate their space.
Göran Henriks
Yeah, so they preferred to go, so we built a pavilion for this patients actually. So they had their own keys booked the machines themselves and took care of the pavilion more or less. There were nurses and there were of course physicians that also oversaw this work.
Judson Howe
Do you see other places in healthcare where this is not being done today, but it should be being done?
Göran Henriks
Oh, it can be done in many places. But I told you before that we are an anxiety industry and risk minimization, and so the biggest constraint is the nurses and doctors that sometimes feel that it's too risky, and they have not a protocol for what patients can do it and not do it.
Judson Howe
It might be awkward as a non-American to answer this next question but I'm giving you permission to humbly answer. If you were Secretary of Health for the United States —
Göran Henriks
Well, that will never happen.
Judson Howe
Okay. So we can imagine.
Göran Henriks
Yeah.
Judson Howe
What would be your top priority for your term?
Göran Henriks
First, I have to say that I admire the speed of change and the results Don Berwick achieved that became Obamacare, where you had a structured approach to help the 50 to 70 million people that couldn’t afford healthcare. And I would start with going upstream and help those people so they do not depend on a situation where they are valued from a money point of view.
Judson Howe
I like that. And then maybe just a different angle on that, but you have experience mentoring people. And if you were ever in the situation where you could mentor an American healthcare executive, what would be your advice for them?
Göran Henriks
I know that maybe someone told me that, maybe it was here in the house, that 60% of the bankruptcy in finances in United States comes from hospital related businesses. I think that I would have tried to make them go outside their own situation and see if there are alternative ways, and be in charge of that change. At the same time, they have to live with the system, but you have to create situations where you have both this short-term approach and the more long-term idea. So you need a theory of change. But if you are stuck in the daily production and the pressure of finding the money to have the machine going, then it's the same thing as for the pediatrician I talked about, that you do not zoom out. But there are so many fantastic things happening in the United States and also in other places that your assets are enormous. But you have to look at those assets in different.
Judson Howe
How do we, if the assets are basketball players on the court, like how do they interplay with each other?
Göran Henriks
Yeah, and for me it is assets of knowledge, assets of very well-organized things. Learn from those places, but you have to go from outside-in and not just run for your own problems. You have to find the pictures, metaphors, ideas that others are doing.
Judson Howe
What would be your advice for someone on how they could best help make healthcare better for themselves?
Göran Henriks
I learned very early that the only way to help people is to support them when they find their own way to do it. And that's the general advice. So promote the solution or the question that the people come up with themselves, and help them to find the answers and help them to go their own way.
Judson Howe
Why do you think that's weak in healthcare today?
Göran Henriks
Because we are in a world where sharp sight ideas are...
Judson Howe
Sharp sight?
Göran Henriks
Yeah, sharp. I mean, we have a logic that it's brilliant to be sharp-sighted and not wide-sighted.
Judson Howe
I see.
Göran Henriks
And we have a habit to be solution-oriented before we have really framed what are the problems.
Judson Howe
That's a perfect segue to my final question for you. One of the things we're trying to do with this podcast is exactly that, to reframe the challenges that we have in healthcare to zoom out and look at the borders of this problem. And I don't have a strong definition of the problem right now because it is so big. I'm in the process of zooming out. But in that process, I've been inspired by systems thinking around leverage points. Where is one leverage point in healthcare that we all could do a better job pushing on to have an outsized impact on the change that we need to see?
Göran Henriks
Honesty is very crucial. And if you have an incentive system that creates everyday situations where you feel that you maybe are not honest in the way you act or have to act or are pushed to act, then it's very tough.
Judson Howe
Be more bold and articulate what you're saying about the American healthcare system.
Göran Henriks
Yeah, and more honest.
Judson Howe
I spent some time asking questions around burnout in the American physician and one thing that continues to resonate with me years later is that the root cause — I should be more broad, a root cause of burnout — is the misalignment of values between why that person chose to sacrifice so much of their time to be a physician in the United States and the experience that they had on the ground. Is that aligned with what you're saying here?
Göran Henriks
Yes. That causes stress.
Judson Howe
And I would say, to interject myself on this one, as a healthcare executive, as an administrator, I also was experiencing moral injury for the exact same reason. And it wasn't until I started to study the ethics of global health and how they spoke significantly — Paul Farmer, for example — spoke a lot about the need for cultural sensitivity in the work that you're doing, and I was realizing that we have grown somewhat in the anti-colonialization of delivery of healthcare in some parts of the world, but we haven't looked in the mirror back in our own communities. So, Göran, I want to thank you for your time today, and I want to thank you for the research that you've done, and the time you've taken to write that, and to influence many of us around the world. Thank you.
Göran Henriks
Thank you very much.