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Hello, I’m Domhnall MacAuley and welcome to this BMJ Leader conversation. Today I’m talking to Göran Henriks in Sweden. You are one of the world leaders in the health care and quality movement but let me bring it back to your childhood, were you always a leader?

Göran Henriks: It depends on when you think of childhood. I am not aware of having any leadership skills before the age of ten, but after that I think I may have shown leadership at times in different sports.

DMacA: We’re always interested in the question of whether leaders are born or made. Does that give us a hint as to your thoughts?

GH: Well, I think that it’s a combination. And I also think there are different kinds of leadership. Some leadership comes when you are asked to put yourself forward. But the other kind of leadership comes from within, when you begin to understand yourself better, and can see different ways of influencing change. For example, if you see that a group needs support and you can try to achieve results within and together with that group but maybe not take traditional leadership position, that’s also leadership.

DMacA: Let’s move on from this age ten to your time at school and college. Tell us about that.

GH: It was childhood with a lot of sport, especially team sports, although I did compete in individual competitions in tennis and table tennis. But I started early with basketball, and the team structure of basketball is important because, in basketball you have five players on the court and five on the bench. You are very involved in the game. It’s not like in football where, when you are on the bench as a trainer/coach, you nearly sit on the sofa! In basketball you are very close to every executed play. And leadership, both as a player and as a team mate, and later as a coach, became a crucial skill for me. Following on from those experiences, I continued on my leadership journey. I studied psychology and have a child psychologist background. At the same time, I was the national coach in basketball for different age group teams. I also have a Master degree in business and have held leadership positions as a Chief executive of Learning and Innovation. Taking all these together, I think that represents a spectrum of experiences where leadership is a natural part.

DMacA: Let’s go through those three components. We’ll start off with the psychology- what brought you to psychology?

GH: My drive was to learn how we act in different challenging situations and to understand more deeply what kind of support we need, mentally, to become stronger in different key executive situations.

DMacA: And then moving on to coaching basketball, where you coached at a very high international level, tell us about the lessons from coaching sport.

GH: There was so many lessons, its hard to identify for the reader one particular lesson that would be most fruitful but, when you are in a team I think it’s very important to understand that you shouldn’t only look at your own performance and what you personally contribute to the team’s results. But, you should be a team player and do what is best for the team. It is the whole teams result that counts. And, its crucial to develop that understanding in the coaching role. It’s a lesson that is also transferable to our daily work life, where we are often focused on our own role and performance, and maybe not enough on how we can help others to do their job well.

DMacA: Are those skills transferable to senior management posts?

GH: Absolutely. And I think that the secret of senior management is to balance your own capacity, of being transparent, and take positions, and have your feet on the ground, and believe in what you’re doing, together with a deep understanding that the result does not come from what you alone do, but it comes from all those colleagues who value you as a leader. It’s the players who make the coach successful, it’s the employees that create the successful boss.

DMacA: And the third component was the business component. After you had studied psychology, you took a little turn in the road and you did an MBA. Tell us about that.

GH: In healthcare we often focus on being productive and fast, creating new initiatives, and on executive action. And we also tend to reduce both the technical resources and people as resources. But, the secret of performance in healthcare is to do the right thing from the beginning and to value the outcomes of clinical processes. If you can design your daily work to reduce outcome variation and always do the best possible from the very beginning, the financial outcomes will also be good. But, because of the pressure of time and speed, we are sometimes blind to that competence.

DMacA: So equipped with all these qualifications, expertise, and experience you set off on your career. Tell us about your career.

GH: I have been the Chief Executive of Learning and Innovation for 28 years in the same organisation and, in total, I have worked for 44 years in that same system. You might ask why I haven’t changed to another place? Well, in sport, you learn very early that the secret to achieving results is not to compete with someone who is the best in the world, it’s much better to compete with teams that are close to your own performance, or just a little better. So, over the years, I have practised that logic model and said to both myself and my healthcare organisation that, instead of us traveling and trying to find people that are similar to us, why don’t we develop a system where people love to come to us to learn. We can show them what we have and we know that, by having our employees show what they are doing, every time they do that they take another step in understanding what they do themselves. When you talk about what you do yourself, you always try to be as clear as possible in your explanation, and that develops your own learning.

DMacA: When you talk about developing your own learning, perhaps that’s a hint to the answer to my next question when I ask, having spent so long in the one institution,how do you keep fresh and how do you keep bringing in new ideas?

GH: I think the secret is in systems thinking. My organization is just a part of a bigger system and we depend on many stakeholders and networks. We are not always the cleverest so we have to be curious about whats happening around us. By being curious and collaborating with our stakeholders, using resources next to us, and with other health care systems in Sweden, we gain more and more ideas that we can then integrate into our own work. And that has been the idea- that by harvesting what others are doing, we can also improve ourselves.

DMacA: You talk about this internalization and bringing people in which would suggest that your work has all been focused within your own institution. But that’s not true because you have a huge international profile and you’ve worked with Institute of Healthcare Improvement (IHI). Tell us about your work with IHI.

GH: In 1996 I participated in my first national forum in the US, and I was astonished by their enthusiasm about reducing the gap between how things are and how things could be. The people who were in leadership positions then, Don Berwick, Maureen Bisognano, Tom Nolan, Brent James, Paul Batalden, they all influenced my thinking a lot. And I also saw that this improvement science they talked about was very close to the approach I learned from sport- you have to improve your skills in small steps every day. That’s what improvement science is all about, it’s not possible to take big steps along a dyke, you can only take small steps otherwise you fall into the dyke. It’s the same thing both in sports and in this knowledge platform.

Together with my colleague, Mats Bojestig, we were so thrilled about our experience at this forum that we asked our CEO to come with us the following year. He was a statistician and he realized that, if we could become successful in 30 to 40% of all our improvement efforts, that would be the cheapest effective way to develop new performance levels within the system. With no change, we would not achieve anything. And, yet we saw that there were so many change ambitions in the structure that did not really change the quality. We started to understand that, on the deeper level, if improvement efforts are successful to 30 or 40%, that may be the best score that can be achieved in our business.

DMacA: You’ve brought this message from beyond IHI, to the International Quality Forum, and that’s spread all over the world. Tell us about the International Quality Forum.

GH: In collaboration between BMJ and IHI, I have been involved in chairing the conference design over the last 20 to 25 years. And, this has been important, and together with the rest of Sweden and the Scandinavian countries, we have seen that by implementing the science of improvement, it has been possible for us to show that there are alternatives in hospital care that give the patient a better experience. The international conferences are a symbol of how we can do things together, and it’s a very positive collaboration. Between 2000 and 3000 people come every year, and they are there because they know that they will find friends and colleagues in similar positions who are asking the same questions.

And, another major benefit of this conference is that you realize that your problems are not unique. We are in a global community of development where the same problems seem to be everywhere. Today everybody talks about competence; lack of competence, IT struggles, AI challenges. So why should we sit and looks for solutions ourselves instead of creating meeting places where we try to learn and do together.

DMacA: We’ve talked about the abstract concepts, and we’ve talked about management, and about the international component. So, finally, let me bring you back to the individual. Tell us about ‘Esther’.

GH: Another secret of improvement science is that people do not learn at the abstract level, they learn from strong narratives. One of the more important things we understood early on, was that the situation regarding the elderly was not acceptable…. it’s not acceptable that an elderly person in our system might suffer from poor access, overcrowded emergency rooms and lack of daily support. We understood that people over the age of 80 years of age need a different kind of system.

The story about ‘Esther’ starts from the negative experience of an elderly woman that led to us to a patient focus and a deeper understanding of our challenges. Esther is an old woman and it covers her journey from a day when she had swollen legs and a bad headache. And she called her daughter. The daughter comes and finds that they need to call the district nurse. And the nurse comes to the home, finds Esther in a bad condition, and they call an ambulance. They go to the care centre and its overcrowded with no doctor available. During the lunch break the doctor sees Esther and after some lab tests they realize that she has to go by ambulance to the hospital. And when she comes to that hospital, it’s totally overcrowded. And, at 8.30 in the evening, the young doctor with no experience, comes up and says, “Esther, you have to stay overnight”. She goes up to the ward, and not having eaten for the whole day, she is given white bread with cheese and a glass of milk- her only meal that day.

When we realized that this story was not unique, and that this was how we treated our elderly people, we wrote this narrative about ‘Esther’ and have kept that as our key change thinking tool. Today, we have more than 75 people engaged in a living library of patients’ experience of care. So, when we do improvement work today, we invite people from the living library to join the improvement processes, and that gives us the strength to always have a focus on why we are here.

DMacA: Such a lovely note to end on- why are we here? And that should be the focus of health care.

It’s been such a pleasure and a privilege to chat to you. From the very first time I heard you speak at the International Quality Forum, I’ve always been inspired. Thank you.

Mr. Göran Henriks, Senior Strategic Advisor, Region Jönköping County, Sweden

Mr. Henriks’ academic background is in Psychology from the University of Lund, where he worked as a child psychologist. He holds a Master’s degree in Business Administration from University of Gothenburg.

Mr. Henriks has been Chief Executive of Learning and Innovation in Region Jönköping for 27 years and has more than forty years’ experience of management in the Swedish healthcare system.

Göran is a board member of the Swedish Institute for Quality and the chairman of the South East Health Care regions Quality registers centre. He is also the chairman of the Strategic Committee of the International Quality Forum organised by the British Medical Journal (BMJ) and the Institute for Healthcare Improvement and a Senior Fellow at the Institute of Health Care Improvement. In addition he was also appointed as professor in Quality Management at University of Yerevan, Armenia.

Professor Domhnall MacAuley

Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.