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Sustaining Improvement? The 20-Year Jönköping Quality Improvement Program Revisited

Staines, Anthony PhD, MBA, MHA, MPA; Thor, Johan PhD, MD, MPH; Robert, Glenn PhD

Quality Management in Health Care: January/March 2015 - Volume 24 - Issue 1 - p 21–37
doi: 10.1097/QMH.0000000000000048
Original Articles

Background: There is scarce evidence of organization-wide and sustained impact of quality improvement (QI) programs in health care. For 20 years, the Jönköping County Council's (Sweden) ambitious program has attracted attention from practitioners and researchers alike.

Methods: This is a follow-up case of a 2006 study of Jönköping's 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 county councils' performance, Jönköping had improved its ranking since 2006 to lead in 2010. Five key issues shaped Jönköping's 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.

University Lyon III, France and Fédération des hôpitaux vaudois, Prilly, Switzerland (Dr Staines); Medical Management Centre, Karolinska Institutet, Stockholm, and The Jönköping Academy for Improvement of Health and Welfare, Jönköping 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 (

At the time of the study, J.T. was director of the Jönköping Academy for Improvement of Health and Welfare at Jönköping University. The Academy is funded in part by the Jönköping County Council, along with Jönköping University and the municipalities in Jönköping County. A.S. and G.R. have no competing interests.

The study was commissioned, and partly funded, by the Jönköping Academy for Improvement of Health and Welfare, Jönköping 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.

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