Magic bullets. As senior leaders in the Canadian healthcare system, struggling with financial pressures, quality and patient safety issues, staff morale and staffing challenges, and the scrutiny of the public and government, we often wish there was a magic bullet - a single, foolproof solution. Chief executive officers (CEOs) tend to be voracious readers of journals and books that profile successful leaders and organizations, looking for findings we can apply to our organizations with similar results. We recognize, of course, that enacting positive change is not that simple. It takes our personal leadership to interpret these findings in the context of our own situations and to determine what, if anything, will fit. Without apology, all leaders should beg, borrow and steal good ideas that will improve quality of care, quality of work life, financial performance and public confidence in our health systems.

Over the past decade many strong organizations have surfaced as leaders that Canadian health system CEOs would love to emulate. Those of us familiar with the Institute for Healthcare Improvement (IHI) are extremely impressed with what we hear and see from organizations that have won the Malcolm Baldrige award and/or have been part of the Pursuing Perfection project. At times, the CEOs of these largely American hospitals and health maintenance organizations (HMOs) appear to be a privileged inner circle that others can only admire from afar, hoping that a little wisdom will rub off to help us achieve some modest success.

In the midst of this esteemed group has surfaced Jönköping County Council. This organization has a name most North Americans struggle to pronounce and is situated in a part of Sweden most of us would not be able to locate on a map. Yet, as the case study authors point out, Jönköping has been cited as "a model of healthcare system transformation that ranks among the best in the world." Wow! Perhaps we have finally found it. Could Jönköping have the formula that will help us move from a series of quality improvement efforts, with variable results, to a high-performing system that demonstrates how care should be provided? Many people think so, as evidenced by the numerous articles that have been written about Jönköping and the throngs of disciples who travel to Sweden to see the system in action.

First, let's look at the results. These are truly impressive. Jönköping achieves the best overall ranking in Sweden for efficiency, timeliness, safety, patient centredness and effectiveness. With regard to efficiency, savings are approximately 2% of net costs. The ability of Jönköping's organizations and units to reinvest cost savings has created buy-in and momentum for change, while explicitly linking corporate strategy, quality improvement and fiscal responsibility. Timely access to services, including access to specialists, has been achieved through alignment of capacity and demand, open access scheduling, strategies to reduce demand for in-patient services (including a 20% reduction in department of medicine admissions) and redeployment of resources to the community. Patient-safety results include a dramatic reduction in sepsis, a 30% increase in influenza vaccination rates and reductions in both morbidity and mortality. A patient-centred approach, epitomized by the Esther initiative, has brought patients and clinicians together in a joint effort to improve the system. Further, Jönköping's focus on removing waste and improving quality as a means of cost reduction has demonstrated that quality improvement and improving care effectiveness are good business strategies.

Indisputably, the results from Jönköping are impressive and have been sustained over a significant period of time. This suggests that it is worth taking a much closer look at this Swedish model to see how these results were achieved.

Much has been written on this topic, and others more familiar with this system will offer their opinions. It has been suggested that political stability and leadership continuity over almost two decades have been important to Jönköping's outcomes. Visionary leadership has been credited for some of the success. Putting quality at the centre of strategic and business planning has also frequently been cited. Learning from others, engaging clinical leaders and building in-house capacity for large-scale staff education in quality improvement also appear to be critical. Alternative funding models for physicians and the willingness of health professionals to adopt expanded roles and new models of care likewise enabled many changes.

None of these concepts is new - change management literature, healthcare conferences and journals endlessly preach these ideas. In our own way, Canadian health system CEOs try to live them in our own organizations. We know that visible, passionate leadership from the top is essential for quality improvement. We know that true system transformation cannot be achieved by a series of disconnected quality improvement projects owned and led by the converted. We know that many effective quality improvement strategies have been tested elsewhere and can be adapted to our organizations and environments. We know that staff engagement, particularly among staff members and physicians directly involved in patient care, is more likely to produce results that are real and credible.

Why, then, is change so difficult to effect? Why do we struggle so hard to make the strategic investments needed for quality while maintaining operations and meeting the demands of our government accountability agreements and public expectations regarding access? Why are we so easily discouraged when short-term, often politically motivated agendas seem to run counter to our longer-term strategies? How do we provide leadership that is strategic, persistent and inspiring?

On the surface one could attribute much of Jönköping's success to IHI. Early in their journey, senior Jönköping leaders attended the annual IHI forum, during which they developed a deeper understanding of process and systems-level improvement, improvement methodology and the need to build workforce-wide capacity for improvement. Jönköping's leaders developed an informal relationship with IHI and tapped into that organization's expertise and training. They participated in IHI's Breakthrough Series and adopted IHI's focus on clinical microsystems as a focus for their own improvement work. And they self-funded their participation in Pursuing Perfection, achieving financial and clinical results that outperformed all other Pursuing Perfection sites.

There is no question that IHI contributed to Jönköping's success. In many cases, IHI served as inspiration. Jönköping's leaders leveraged IHI and the Pursuing Perfection collaborative to build capacity for improvement and adopt leading practices. Fortunately, IHI is now helping to spread the word about Jönköping's success and the learnings we can all take from its experience.

But for me, as a CEO, I need to view Jönköping's success through a leadership lens. To a large degree, Jönköping's success is a result of inspired, persistent, transformational leadership by CEO Sven-Olof Karlsson and other senior leaders whom he selected to lead this remarkable organization.

Let's look at this facet a little closer. The literature on transformational leadership often describes four characteristics of this leadership style: idealized influence, inspirational motivation, intellectual stimulation and individualized consideration. Embedded in the description of Jönköping are many examples of how transformational leadership succeeded.

It appears to me that Karlsson's leadership style was, at the very least, a critical success factor. By personally attending the IHI forum, he modelled idealized influence through his willingness to learn. Karlsson was open to new ideas that challenged the status quo, and he strategically invested in learning and the establishment of Qulturum as a building block for Jönköping's quality improvement. Through his lengthy, stable leadership, Karlsson also established strategic alliances with government to build trust and buy time for results to be realized. Karlsson and Jönköping's other leaders likewise built strategic partnerships with a medical school, other health professions' programs and physicians to help build learning and research capacity related to quality. By engaging clinical leaders and the public and by measuring and communicating results, Karlsson built trust and pride as improvements were achieved.

What lessons do I take away from these endeavours? Never forget the responsibilities senior leaders have as role models and the importance of building strategic alliances that build trust. Above all, brag shamelessly when things are improving because doing so will help instill pride in hard-earned achievements.

Transformational leadership also involves inspirational motivation: the ability to communicate a compelling vision clearly and confidently. Such communication inspires and supports individuals to excel, confident that extraordinary results can be achieved. For me, this aspect of transformational leadership is exemplified by Jönköping's continuous efforts to do better, even when it was exceeding the performance of other county councils.

The illustration depicting Jönköping's improvement journey as a development stair illustrates this effort. Leaders believed they could fundamentally redefine their system by demonstrating a constancy of purpose, investing in learning and realigning resources.

And what lesson do I take away from this? A leader's clarity of vision, willingness to set the bar high and confidence in the future can positively infect a whole organization. That is our job as leaders.

So, we health system leaders influence and inspire. Yet even that role is insufficient unless we also provide intellectual stimulation. Jönköping's leaders excelled at doing this. They tapped into the world's leading quality experts as coaches. They leveraged IHI teachings and programs. By reinvesting savings at the clinical microsystem level and requiring staff members to self-fund most improvement initiatives, Jönköping's leaders empowered people to make changes.

They supported this work by building capacity at a scale few of us have ventured: 4,000 of 9,000 staff members trained in quality improvement methodology. This investment in intellect acknowledged the talents and dedication of the people within the organization, with extraordinary results.

What lesson do I take away? Simply that good intentions are not enough if people do not have the knowledge and skills to make improvements. We need to make these strategic investments at a much larger scale in order to build capacity. We must then create cultures in which quality improvement initiatives become self-funded throughout our organizations. Quality as our primary business strategy needs to become our new mantra.

Influence, inspire, stimulate intellect - sounds like that list should be enough. But transformational leadership is also about individualized consideration, caring at a personal level for those with whom we work. I do not know enough about Jönköping to assess whether this aspect of transformational leadership characterized its leaders.

References in the case study to future uncertainties, however, serve as warning bells. Even when inspired and equipped to achieve, staff members are human and can feel overwhelmed. The fatal flaw of many leaders is to be overly ambitious, to be focused on so many results that their systems implode from the sheer weight of all the projects. This is where individualized consideration becomes so important. Leaders need to constantly check the pulse of their organizations and the people who work there. They must look at both high-level corporate results and the impact of those efforts on the morale, quality of life and well-being of staff members. In healthcare organizations we tend to do this poorly. For me, the Jönköping example is a powerful reminder that I need to strive unwaveringly for a balance between transformational change and supporting and caring about the people who help achieve that change.

There are many ways to analyze Jönköping County Council's success. And there are many critical success factors that warrant deeper understanding so we can apply these learnings to achieve success in other health systems. Transformational leadership is not the only answer. However, through the eyes of this leader, it is an important ingredient and one that inspires and motivates me in my own leadership journey.

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