Confidence Report 2014 by Lumen Behavior

CARING FOR EVERY INDIVIDUAL CONFIDENCE REPORT 2014

“Good service means being so secure in your professionalism that you dare to be personal.” EMELIE HJELM BONIN, ONE OF FRÖSUNDA’S 206 BUSINESS MANAGERS

CONFIDENCE IN FIGURES Here we report the results of our business and activities in 2013 and the combined efforts we have made to continuously improve the quality experienced by our customers.

6 CONTENTS

A word from the CEO.................................... 4 Our history..................................................... 6 Our customer groups................................... 10 FrĂśsunda is growing..................................... 12 Vital work....................................................... 14 Quality of life.................................................. 15 Focus on leadership..................................... 20 Meet the management team....................... 21 The CEOâ&#x20AC;&#x2122;s customer groups......................... 22 The confidence report in figures................. 23 Patient safety report..................................... 30 3

Key figures..................................................... 31 The quality pyramid...................................... 34

WE BUILD CONFIDENCE WITH COURAGE AND TRANSPARENCY IN 2013 WE FOCUSED HEAVILY on developing our quality, and our customers have given our efforts top marks. Customer satisfaction totaled at 91% within disability and personal assistance. We have won all the new assistance procurements we have taken part in during the year. This naturally makes us proud and shows we are on the right track. But we are also humble in the face of the shared social challenge that lies ahead of us. How can we provide good health and social care in the future when there is more and more people to be looked after and fewer and fewer people available to do it?

INDIVIDUAL CARE Our experience and knowledge has convinced us that care in the future needs to be much more tailored to the individual than it is today. A move like this would address many of the problems that exist within the care system. And we want to have the whole sector behind us. It is not acceptable that the people we are there for, our customers, should need to be forced into existing structures and be forced to settle for care based on a template. Instead, we as a sector need to take the legal requirement for individual choice seriously and create a care system that always concentrates on the specific person. The power has to be handed over to the customer. Both the clients and we providers have to play an active part in this transfer of power. Putting the customerâ&#x20AC;&#x2122;s needs and wishes first. On that basis, we can look at the skills, leadership and organisation that we need in order to adapt our activities to the task in hand. 4

THE CUSTOMER CAN JUDGE THE QUALITY The customers are also the people who can give us answers in terms of what constitutes good quality. All

of Frösunda, from senior management to each individual employee must act on what the customer needs and wants. But without meeting them, we can never know whether we are on the right track. That is why I have reference groups of customers within each of our four business areas. I meet each group four times a year and they are the most valuable meetings I have. An important part of the quality work has been our strategic investment in leadership. In 2013 I travelled the whole country and met all of our 240 managers. This is a major part of the work towards expressing our values in the way we act and behave. Our core values – respect, commitment and curiosity – must be present in our dealings with customers, carers and clients. We can only say we are delivering good quality when these three players tell the same story.

COURAGE AND TRANSPARENCY Trust in our care is created by acting with courage and dealing with our shortcomings in a transparent way. We put our customers’ interests first. Whatever happens. This means addressing issues that are tough and complex, which affect the whole sector and are crucial if we are to look after each other in the future. One such issue is how we are to ensure quality in the care we provide. It is true that we do not have any measurable parameters at present, but one thing is certain – regulating staffing in the care sector is not the way forward. We want the flexibility to deploy resources where they are needed by our customers. At the end of their lives, for example. Or it could be something as simple as prioritising staff in the daytime when the customer is awake and therefore might be active, rather than double-staffing at night. We want the flexibility to bring in the skills needed to care for every customer. To reinforce what is working by focusing on health and capability, based on every individual’s needs. We want an increased focus on supervision and inspections by the authorities so that no customer need have a provider who is not up to the job. We

welcome external monitoring and tougher demands on those accountable, but not because we never make a mistake. We do. In an organisation with 8,000 people mistakes will always be made. But our firm commitment is that we will always take responsibility when something goes wrong – both to rectify the situation quickly and learn from it as an organisation, and to prevent similar situations in the future.

INNOVATION I have followed and assisted in the development of care since I was twelve years old and spent a whole summer taking elderly people out in wheelchairs for eight kronor an hour. That was in the 1980s, and a lot has happened since then. We have new gadgets and alarms and, above all, increased respect for the individual. But major innovations have been slow in coming years. We are now in a position where the need for innovation is more pressing than ever. We can also see that there is plenty of room for it. This is especially true of social innovation. Opening up to more categories of people and more types of accommodation. Not everybody wants to live in the same way. Our customers are not a group, they are individuals who need and are entitled to special support. There must be options for those who want to have pets or to live with their friends – quite simply to make their own choices in life. On the technical side, it might be communication or alarms – or why not robots to help individuals in the areas where their need for independence is greatest? What we need is a system that encourages rather than hampers innovation. This means scope for providers to find the new solutions. And there needs to be real customer choice in all segments, because that is when we will see whether the innovations are working and adding value. We also need a game plan where the rules are laid down in the customer’s best interests – so that all players, both private and public, are monitored and maintain the same high standards. The biggest risk right now is that we as a sector could

become defensive. That fear could go on impeding development. Instead we need courage. The courage to develop and take responsibility when we make mistakes. That is our continued mission for 2014. To display courage and transparency and prove ourselves worthy of trust from our customers and clients. SUSANNE SIDÉN CEO

With our experience, knowledge and aims for the future, we know that care needs to be much more tailored to the individual than it is today. There are solutions to many of today’s problems within the care sector. What constitutes good quality has to be decided by the customers – recipients, carers and clients. We can only really say we are delivering good quality when these three players tell the same story. Trust in the care we provide is created by acting with courage and dealing with our shortcomings in a transparent way. We do not hesitate to show that we put our customers’ best interests first. If we – clients and providers together – are to develop economically, socially and environmentally sustainable care, we need completely new innovations.

TOWARDS A WORLD WHERE EVERYONE CAN PARTICIPATE IN SOCIETY

Frösunda was founded in 1994, but our roots go back further in time – via the 20th century human rights movement and an increasing understanding of individuals in need of special support. Come with us on a journey to the Frösunda we are today. From our origins in personal assistance, through key policy decisions and a growing care sector. And on into the future – where innovations will create new requirements and we will continue to drive social change towards a world in which every individual’s resources are utilised. 1948

1979

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1999

SALUTOGENIC APPROACH Professor Aaron Antonovsky publishes his research on the salutogenic approach for the first time. The salutogenic perspective focuses on factors that cause and maintain good health, rather than what causes illness. The salutogenic approach is a cornerstone of Frösunda’s work.

3 1 The Universal Declaration of Human Rights is adopted by the 6

The National Action Plan for Care of the Elderly, which stipulates that care should be publicly financed by tax revenues and available according to need, not ability to pay.

UN General Assembly. Recognition of the inherent dignity and equal and inalienable rights of all members of the human race is the foundation of freedom, justice and peace in the world.

THE ELDERLY REFORM ACT (ÄDELREFORMEN) is passed in Sweden, shifting the responsibility for the health and social care of elderly and disabled people from the county councils to the municipalities. These are also called upon to establish specific types of accommodation to provide service and care to persons in need of special support. The municipalities have been a major customer group for Frösunda from the outset.

“What is so good about Frösunda is that they have always been serious. I feel I have a good life and I am listened to.” INGA GLENHAGEN, A CUSTOMER OF FRÖSUNDA SINCE THE START IN 1994 Frösunda starts its activities after the “assistance reform” comes into force and establishes the right to personal assistance and an independent life. Right from the start there is a belief that every individual can participate in society.

Laws regulating discrimination against people with disabilities in the workplace are adopted. Today, 5 out of 10 people with physical disabilities have no connection to the labour market.

THE WHO ADOPTS THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF).

The UN Convention on the Rights of Persons with Disabilities is adopted with the aim of enhancing protection of the human rights that persons with disabilities have under the existing conventions.

The system is a tool for assessing the whole of an individual’s life situation, how different life activities work and how active the individual is in society. The ICF throws new light on the concepts of “health” and “disability”. It recognises that anyone may experience a decline in health and hence some degree of disability. So disability is not something that only happens to a minority, but a universal human experience. By shifting the focus from what caused the disability to how it affects the individual, it becomes possible to compare and measure using a common scale – the ICF. In 2013, Frösunda became the first care organisation in Sweden to start implementing this system in all business areas.

2001

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2009

10 The human dignity study presents ‘Dignity in the Care of the Elderly’, a SOU (Swedish Government Official Report) founded on everyone’s right to a dignified life. Elderly people should be helped by the care services to live according to their own identity and personality.

Frösunda has grown and now addresses a broad target group of disabled people who need different levels of care and support with things such as day-to-day activities, coaching, special schools and separate accommodation.

The UN Committee on the Rights of the Child is again concerned at the large number of children in Sweden who have been taken from their families to live in foster homes or institutions. This concern is based on the latest figure of 23,000 persons (aged 0–20). Today the figure has increased to almost 30,000 individuals.

12 13

LOV

The Act on Freedom of Choice (Lag om valfrihetssystem – LOV) is passed, allowing municipalities to expose services to competition by leaving the choice of care provider to the person who will actually be receiving the services.

Frösunda develops its own method of working. This is called the “My” method, and aims to ensure that we work on an individual basis according to the customer’s personal situation and wishes.

On 19 September, the medical officer at Koppargården elderly care unit wrote that she no longer felt able to guarantee medical safety for the elderly. This kicked off an intensive period of media attention and debate. In six months, 4,000 articles were written about unsatisfactory conditions, weak leadership and ownership models. This resulted in a major crisis of confidence throughout the entire sector. Although some facts are still being debated today, this undoubtedly led to greater demands for transparency, a focus on quality and the value that carers give to the elderly and to society as a whole.

“When I heard about the elk hunt, I was very excited! Since I have been in a wheelchair I haven’t really been able to get out into the countryside. That is what I look forward to most, just being out in the open air. But it will also be nice to sit in the hide and listen to the silence.” Ryno Eriksson, talking to Swedish Television (SVT) about Frösunda’s hunting weekend

2010

2011

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2012

“It is good to have these meetings – provided that they make a difference.”

“We see anonymity as a matter of trust for the whole sector and we support the idea of complete openness and transparency in health and social care. A system of anonymity that takes a neutral view of different types of operation is a big step in the right direction.” Susanne Sidén, CEO of Frösunda

So says Oskar Pettersson of his meeting with Frösunda’s CEO Susanne Sidén, highlighting this year’s key word in the field of sustainability, “responsiveness”. Professor R. Edward Freeman’s term simply means that discussions with stakeholders, such as when Frösunda’s CEO has regular meetings with customers, must lead to improvements.

2013

“What I have found hardest about living at Frösunda’s Pandion care home is that I don’t get enough time to myself. Going from living with a mother who is at work all day to living with seven others plus staff was a big change.” OSKAR PETTERSON, 18 FOOD, FOOD, FOOD Since 2011, Frösunda has assisted social services with health and social care for children, young people and adults. For us, individual and family care means giving both young people and adults the help they need to live 8

a worthwhile life. We give adults support with parenthood and help young people to manage their own lives.

First, ANNA-CARIN AHLQUIST, Team Frösunda’s table tennis star, takes gold at the Paralympics in London. Then she is nominated in the ‘Female athlete of the year’ category at the Swedish Athletic Gala. This is the first time a disabled athlete is nominated in the same category as able-bodied athletes.

– all over social media. And now researchers from Harvard Business School have shown that all this can make food taste better. In an article in Psychological Science, they describe how rituals (like always sending Instagram photos) surrounding food increase engagement and hence enjoyment. At Frösunda, we know this is true – although the rituals surrounding meal times in our elderly care units do not normally involve smartphones. On the other hand, the colour, smell and taste of the food, how it is presented on the plate, eating in peace and quiet and sitting with people you like to be with does make a difference. Food is an important element of our customers’ quality of life, and Frösunda’s dietician ensures that the catering staff are trained to make meal times as good an experience as possible.

People who used to be students have now become business and quality managers in the health and social care sector. They have their own view of quality, with the customer at the centre – as shown by Frösunda’s survey of 300 social scientists and students in 2013.

What should come first when plans are made for an elderly care unit? The customers should be able to sleep whenever they want The staff should have full-time contracts

89%

The accountants and their profit margins

2040 2018

THE FUTURE 21

2020

VISION We aim to be the obvious choice in the Nordic region and a role model for how social care can be provided in a responsible way and with high quality.

MISSION We earn trust by taking responsibility.

VALUES 22

More than a fifth of the Swedish population are over 65 – and over 10% of people who are children today are expected to live to be over 100.

RESPECT – through a dignified and individual approach, we create security and happiness.

PERSONS WITH DISABILITIES, ELDERLY AND YOUNG PEOPLE CAN PARTICIPATE IN SOCIETY

COMMITMENT – we care about people and are proud of what we achieve. CURIOSITY – we actively seek new skills that make a difference for our customers.

23 PICK UP YOUR COFFEE CUP USING THE POWER OF THOUGHT?

It might be possible! In 2013, researchers from the University of Minnesota managed to control a helicopter with a non-invasive technique called electro-encephalography, which uses brain waves. We will see what this and similar innovations could mean for the ability of disabled people to manage their own daily lives when we meet this exciting future.

OUR CUSTOMERS ARE SOCIETY Frösunda’s mission is to create quality of life for people who are in need of special support, whether they have a disability, suffer from dementia or are in a vulnerable family situation. It is a mission that we take extremely seriously. To succeed in it we need to create value for the whole of society around every individual – and this means always having our four customer groups in our minds. That is why we drive change at both a social and the individual level, because it is ultimately about looking at people and making use of their resources.

1. Marlene

OUR CUSTOMER GROUPS Our services have many customers who are all different and have different needs. But whether the customer lives with us, is a municipality or a carer, they are equally important. To understand and maximise the value we are creating in society it is crucial for us to start at the level of the individual customer.

1. CUSTOMERS: The customer is the direct recipient of our services: health and social care within personal assistance, disability, families and individuals, and elderly care. They may be a pensioner who needs support at the end of his or her life, a child seeking asylum or a person with a disability who needs assistance. All our customers are different, with different wishes and needs. Every individual has their own idea of what constitutes well-being and that is the basis for our work. 2. CLIENTS: Municipalities and county councils are the clients for our services, on behalf of their citizens. The municipality or county council makes a decision for each customer and this decision forms the basis for the service. They also define a goal and purpose for the action being taken. 3. CARERS: The customer’s family and friends are our third customer group. 4. INTERNAL CUSTOMERS: Our supply chain encompasses both support functions – Business Development, HR and Quality – and the four business areas. We measure internal customer satisfaction every year.

“FRÖSUNDA IS FLEXIBLE – BOTH MY ASSISTANTS AND THE ORGANISATION. ALL TYPES OF FLEXIBILITY GIVE PEOPLE A CHANCE AT LIFE.” Marlene Bergqvist is a health consultant and advocates a coaching approach. Right now she is working on the “Life entrepreneur” project, which she initiated herself and which gives young people with disabilities the chance to identify their strengths and dreams and reach their own goals. Marlene has been a customer of Frösunda in Umeå for five years. “I had the opportunity to meet the management of Frösunda and understand the organisation’s thinking. That gave me great confidence. So even though things can happen and mistakes can be made, I feel that Frösunda is a good solution in the long term. The basic philosophy is that assistance should allow the person to live their life as smoothly as possible. The best thing is when I can forget the organisation itself and concentrate on my life. Frösunda is there, I have the number, but I don’t have to call it. What is not so good is that the case manager has changed several times.”

“I SEE REAL DIFFERENCES BETWEEN THE TYPES OF ACCOMMODATION, AND WHAT FRÖSUNDA OFFERS IS GOOD.” Ingrid Rosenquist is a legal guardian for a person who lives at one

“IT IS GOOD TO BE ABLE TO CALL A COLLEAGUE AND ASK FOR HELP. THEY ARE THE RIGHT PEOPLE IN THE RIGHT PLACES AND YOU ALWAYS GET AN ANSWER TO YOUR QUESTIONS.”

of Frösunda’s elderly care units Rubinen at Upplands Väsby. As

Robin Taylor is one of Frösunda’s regional managers, responsible

a guardian she has seen both good and bad examples of housing

for region South. His job is to lead the case managers and ensure

for elderly people and care for disabled people.

that they have all the information and knowledge that they need. As

“In the beginning my client was more mobile and then they went

part of his role at Frösunda, he is a customer to the organisation’s

into town, drank coffee and walked around. It is unusual for them to

support functions and they are customers to him. This internal

have frequent outside activities when they live in eldelry care homes.

customer perspective means that everyone has to be treated with

The way staff are recruited is important; their values must match

respect, commitment and curiosity.

those of the organisation. Along with their professional knowledge

“It’s a good feeling to have the support functions behind you.

of course. After all, things can happen when people work with other

We are always breaking new ground and it is important to be honest

people. A couple of years ago there was a terrible situation with

with ourselves and ask for help when we need it. We take pride in

staff who were not up to the job. What Frösunda did then was really

winning tenders and delivering quality, but internally we need to

professional.

have an ego-free culture that encourages openness, honesty and

They contacted us immediately and went out to the unit to take care of the situation. When the organisation is forced to handle difficult situations, you see how things really work.”

3. Ingrid

the courage to own up to our mistakes. This is an efficient way of working on quality at Frösunda. We can stick our necks out and claim to be a quality organisation.”

“FRÖSUNDA KNOWS OUR MUNICIPALITY. THEY HAVE WON TENDERS BECAUSE THEY DO QUALITY WORK AND FOCUS ON THE CUSTOMER.” Jenny Wilhelmsson is head of the Disabilities department and responsible for procurement in Järfälla Municipality, which is one of Frösunda’s local authority customers. “A good provider keeps in touch and lets you know when things are working and when they are not, they take part in the follow-up work and, above all, they maintain high quality in their support to the individual. Frösunda has been active within Järfälla municipality since the early 2000s. Frösunda has become a better provider than it used to be. There were shortcomings in their work that had to do with the attitude of the staff. The staff went for what was easiest for them rather than thinking of the customer. But now it is different. Frösunda has a

2. Jenny

quality department and a regional manager who supports the case managers so they can provide a good service. They also carry out a number of quality checks themselves. I think Frösunda does a good job. I feel safe with them.”

4. Robin

FRÖSUNDA IS GROWING Frösunda was born in 1994 from a fundamental idea that people with disabilities can particpate in society. Now we have just over 8,000 staff delivering care, support and service to elderly people and persons with disabilities or social problems. That makes us one of the leading players in Sweden.

KUNDER

Our background in personal assistance forms the basis for our expertise and knowledge when it comes to individually tailored support for our customers. We carry this with us as we grow within other business areas and reach more customer groups. To move closer to our vision of a world where everyone has a natural place in society The focus in 2014 is to grow within elderly care.

THE GREAT CHALLENGE WE FACE A CHALLENGE of immense proportions. The population is ageing inexorably and nobody today,

be they politicians, providers or pundits, has any solution to this. In the next 15 years, the proportion of GDP going to elderly care will rise by 23%. At today’s prices, that represents a cost increase of 80%. Or more specifically, SEK 97 billion.

At today’s prices, the costs to society of elderly care are set to rise by 80%, an increase of SEK 97 billion.

46,000 NEW NURSES AND CARE ASSISTANTS

76,000

1,860

NEW NURSING HOMES

2.3 million SQUARE METRES OF LAND READY FOR DEVELOPMENT

7.6 million

SQUARE METRES OF LIVING SPACE

230,000

NEW MEALS EVERY DAY

NEW CARE PLACES

2013 COST OF ELDERLY CARE SEK 115 BILLION

2030 COST OF ELDERLY CARE SEK 211 BILLION

INDIVIDUAL CARE LATE IN LIFE FRÖSUNDA HAS ITS ROOTS in personal assistance and there has always been genuine customer choice in this area. The customer chooses his or her assistant and if we do not deliver what they want, we will be replaced. All of the personal assistant’s work is based around the customer’s wishes. Within elderly care there may still be remnants of a widespread view of elderly people as a homogenous group without any differences between individuals. They can still find themselves treated as a collective that is expected to eat and sleep at times that suit the organisation. Frösunda aims to change that. By addressing each individual in a professional and empathic way, we can arrange support on the basis of the individual’s wishes and needs.

INNOVATION WITHIN ELDERLY CARE At present, elderly care is a small business area within Frösunda with just a few units. But we plan to grow with a focus on quality and have our sights set on customer-oriented innovation. “In the 1990s there was basically no innovation within elderly care. It was made up of institutions where the customers wore hospital clothes,” says Linda Wetterberg, regional manager for elderly care, who has worked for 15 years as a physiotherapist and manager in the field of geriatrics. Today, the individual’s own choice is key to everything from food to activities. “We have to remember that there are great age differences between individuals in the group ‘elderly people’. That means we can’t expect them all to want to listen to the same crooner. The elderly people of today

were young in the 1960s and may prefer to listen to the Rolling Stones. It is also important to realise that men and women may have different interests.” The “My” method is a tool that describes our way of working within elderly care from the day a person moves in to the final phase of their life. It describes routines and methods that employees need in order to achieve maximum customer satisfaction. That way, the relationship is built up from the outset and we make a plan together which we also follow up together during the time they are living in the unit. “It is important to talk about the details, such as who should organise birthday parties and what to do from day to day. We also have to talk about the end of life. Elderly people must have a say in planning how they want things to be, and often we can’t talk about that in the last week of our lives; we have to think ahead. Discussions with relatives are also very important – they need information. They often have questions and ideas about the final phase of a relative’s life,” says Linda.

HIGH LEVEL OF KNOWLEDGE To quality-assure the care they offer in the final stages of life, Frösunda uses the Swedish Palliative Register, a national quality register. This describes the last week of life. Regardless of the illness, the aim of this quality register is to ensure that everyone whose death is anticipated by their doctor feels comfortable. “The Palliative Register has improved cooperation between the doctor and the rest of the team in the last period of life. The level of knowledge in elderly care today is high. Qualified risk assessments are carried out, which means, for example, that the incidence of pressure sores is very low in elderly people’s homes. Frösunda’s own unique history has created a culture where the customer is at the centre, which means that we can deliver the individually tailored support that today’s elderly people need. The key word “curiosity” is also important in this expansion. The best way to learn about how elderly people might take their natural place in society is to discuss things with the elderly themselves.

WHEN CRISIS STRIKES Frösunda’s quality work provides us with better and better risk analyses and leads to higher quality in our dealings with customers. But sometimes mistakes are made all the same. In these cases we need to act quickly and apply all the organisation’s strength – flexibility in allocating resources and persistence in getting to grips with the underlying problem. In 2013, Frösunda’s organisation was put to the test in a medium-sized Swedish town. FRÖSUNDA WON a procurement for an elderly

care unit and started preparations for taking over operations. For the start-up, an old Frösunda employee was called in from a nearby unit to reinforce the team. She reported directly on any unsatisfactory conditions. On the same day, Frösunda mobilised its resources. The underlying problems were identified and an action plan was drawn up in collaboration with the municipality. REBUILDING TRUST IN THE LONGER TERM Frösunda has now taken over operations and responsibility for the organisation. The first task for the newly-recruited case manager was to dismiss two employees who had been guilty of misconduct. This was hard both for the manager and for the team, but it was absolutely necessary. The customers’ interests always come first. When the crisis situation was over, the hard long-term work began to rebuild the lost trust caused by the unsatisfactory conditions. This demands great clarity and perseverance on the part of the management, to demonstrate the sort of behaviour that is acceptable and desirable.

EXPERIENCE AND RESOURCES Frösunda has previous experience of dealing with organisations that do not work. This is a challenging situation, but Frösunda has both the resources and the knowledge to bring about rapid change and improvement. As a private player, Frösunda is subject to external supervision, which also provides great security to our customers.

VITAL WORK For Peter Vikström, it is quite literally a matter of live and death to have meaningful work to do. He knows very well what it means not to have one, and what thoughts then take hold.

PETER VIKSTRÖM’S working day at Frösunda in Skel-

lefteå gets off to a good start. The first thing he does when he gets to work is to eat lunch together with his colleagues. Then he starts on the day’s tasks. This may involve a little of everything – sticking labels onto things, feeding sensitive documents into the shredder or other jobs that weigh down an office. Today it is the administrator who needs help with a big mailshot. “Here I feel needed and appreciated for what I do and everyone needs to feel that.” It wasn’t always like this. In his previous workplace he found that he wasn’t given any proper jobs; it was

THE SITUATION IN THE LABOUR MARKET

more a case of passing the time. The days seemed long and Peter became more and more depressed with each day that passed. Finally, he realised that if it went on like this, he would just as soon stay at home.

26% of the population, or 1.6 million Swedes aged 16–64, have some kind of disability, and over half of these have a reduced capacity for work.

SERIOUS DESPAIR

Impaired mobility is the most frequent form of disability among people with a reduced capacity for work.

“It all seemed sad and hopeless, quite meaningless,” he says, becoming serious and quiet for a moment. And it was serious. Peter felt everything was so meaningless that he wondered whether life was worth living at all. He was haunted by thoughts that nobody should have to deal with, and the root of the problem was that he did not feel needed. There was no coherence to give his life meaning. He no longer had any human dignity. “I no longer had any sense of belonging, or any meaning.” It was a tough time and it hit him hard. But one day he had the idea of asking Frösunda whether some job could be found for him there. “I can do absolutely anything, as long as I get to work and not just sit around all day,” he said. Then everything moved very fast. Before two weeks had passed he was working his first shift. He had to sign a confidentiality agreement and was assigned a nice light office at the end of the corridor. There he attends to his tasks one day a week, and they are tasks that he enjoys a lot. “Here you feel needed because you are doing a proper job, something that really takes the load off someone else. Which maybe helps to reduce someone else’s stress. That is important – everyone should feel that.”

71% of the total population are in employment, compared to 44% of those with disabilities. People with disabilities experience discrimination much more often than the population as a whole. This affects their chances of promotion and their salaries as well as increasing the likelihood of rejected applications and dismissal. Bullying in the workplace affects 16% of people with disabilities, compared to 11% of the population as a whole. Research shows that participation in society, not least through work, is crucial to mental health and important from both individual and the social perspectives. Handisam’s survey of 289 authorities in 2013 shows that public bodies seldom employ people with disabilities.

STOP TALKING ABOUT STAFFING So let’s stop talking about staffing as quality. This blocks the view of real ways to provide better quality in health and social care. And it dramatically decreases our chances of finding solutions as we move into a future where more and more people need to be looked after and fewer and fewer are available to do it. IT’S LIKE THIS: we love staffing. We take great pride in

providing staff and it is part of our core business. The right person in the right place at the right time providing health and social care in order to create the best possible quality of life for every single customer. And the numbers of customers are increasing all the time. By 2030 the number of people aged 75 and over will increase by 60%. In the same period, the number of people in their most economically active years between 20 and 65 will increase by just 4%. As a society we are faced with the question of how to tackle the burden of care. It is a question that Frösunda takes extremely seriously. And one thing is certain: if we measure quality in terms of exact staff numbers, there will be no way for the organisation to be flexible and agile. And no room for innovation.

On the other hand, there is a way if we look at our common objective and our different roles on the way there. Municipalities and county councils set the objectives. Frösunda, like all public and private providers, guarantees to achieve these goals – in the best possible way. The IVO reviews the results, and we would be happy to see tougher demands for action when a provider falls short of the mark. We can then make room for innovation together. When we, the providers, take responsibility for how the goals should be achieved. It is hard to measure the social value that health and social care should provide. But others have succeeded in their fields; the IT industry, for example, has concluded that service availability is the obvious measure that is demanded in public procurements. A transparent measure of the value of good health

START FOCUSING ON INNOVATION You can read about our “Perma” pilot scheme for measuring quality of life below.

and social care is the ambitious aim of Frösunda’s latest investment in research and development. “Right now we are investing in a new evidencebased method of measuring quality of life,” explains David Fredriksson, Head of Business Development. “This is just one of our contributions to drawing up a new customer-oriented standard. Whether we end up with quality of life or some other measure of customers’ well-being, only time will tell. But this is one way in which we take responsibility for driving our whole sector towards innovation in the interests of our customers.”

MEASURABLE QUALITY OF LIFE FOR ME AND ME. The value that Frösunda provides society is the quality of life of its customers. Actually measuring quality of life as experienced by the customer is a respectful and transparent way of taking responsibility for our job – and goes well beyond the modest standards for the profession. That is why Frösunda has become the first Swedish company to test a tool developed by researchers at Penn State University in the USA. Quality of life measurement captures how well Frösunda is doing in different parts of its activity and over time. It is an important instrument for understanding the core of Frösunda’s mission, building trust and helping management. WHAT DOES WELL-BEING MEAN TO YOU? We often think of well-being in terms of happiness: what do we enjoy? But there is more to it than that – a good life includes the chance to get involved, to feel part of things and to be absorbed in something you find meaningful. Quality of life also means relationships, ties between people and a sense of belonging. We also need to feel we are reaching our goals, that we have direction and meaning. Quality of life includes all these components for everybody, but of course their proportions and what meets the various needs will vary. Quality of life (or well-being) is a measure developed by Dr Seligman, a leading figure in happiness research. The theories have developed for decades and have led to the “Perma score” tool. The five components of well-being are captured with 24 simple questions.

RESEARCH-BASED DEVELOPMENT WORK

Our job includes measuring results and monitoring quality work. At the same time, we are humble in the face of the task – measuring how a person feels is a complex matter. Many of our customers, such as young people placed under the Care of Young Persons Act (LVU), have not chosen to be in touch with us. They would rather get on with life without any support. We take regular measurements that more explicitly relate to our approach and the customer’s satisfaction, but it is not enough. We need to be able to measure how our

customers perceive their well-being, regardless of what they think constitutes a good life. We must dare to ask how they feel and how they are doing, for real. This year’s survey is our first pilot. The sample was small and we cannot draw too far-reaching conclusions. What we can say, however, is that we have found a measure of well-being that will work in our business. The tool is still under validation at Penn State and the fact that we are testing the method in a Swedish context has aroused great deal of interest among researchers in the USA. The measure works in such a way that one can produce a profile for an individual, a unit or a business area. Isolated measurements provide limited information, but by repeating the measurements over time, one can collect very valuable knowledge of changes taking place in business. For example, if the values for a unit drop, we need to ask ourselves why. Have they changed their manager? Has something happened among the customers or staff? There is also interesting information to be gathered when contracts change hands. What value do customers get from the change and what happens when Frösunda has managed the operation for an extended period? The measurements also pick up negative feelings. Although the focus is on positive aspects, it is important to note that some of our customers feel great loneliness and anxiety. We need to remember that they are living in a vulnerable situation when we look at the results, but we must never compromise on our mission to deliver the best possible quality of life.

FREEDOM FROM DRUGS

WORKING

Life will be completely different, better. Viktoria, 27

Going to work, having a workstation and doing a job. Karl, 43

GREEN FINGERS

SEVEN KINDS OF BISCUIT

Dirty fingers, but I don’t care. Nellie, 18

Coffee and biscuits in the morning. Harry, 84

MEASURING QUALITY OF LIFE Five parameters for well-being P Positive emotions: Feeling happy E Engagement: Feeling involved R Relationships: Being happy with your relationships M Meaning: Feeling that life is meaningful A Accomplishment: Achieving your goals

Researchers have found common features of a good quality of life – relationships, a sense of meaning, positive feelings, commitment and activity. But exactly what brings each person to experience this is an individual matter. To work for the best possible quality of life we need to listen to every single customer. Here, some of our customers explain what well-being means to them right now.

FRIENDS

THE FUTURE

HELPING OTHERS

I DON’T KNOW.

BEING AT THE STABLES

AT THE GYM

Doing things with my friends. They understand me. Johan, 37

Well-being is knowing what the future holds. Selver, 18

When I can help other people. Maria, 16

Not a bloody clue. Mattias, 25

When I am in the stables with the horses, that’s what I call well-being. Marlene, 27

The best times are when I’m out training. Anna, 24

A WALK

SUMMER EVENINGS

NEW PLACES

MUSIC IN MY EARS

A GOOD LAUGH

PEN AND PAPER

The best thing is when I can go for a walk outdoors. Kristina, 54

A mild summer’s evening with my friends. Emma, 21

Well-being is travelling and seeing new places. Christoffer, 30

When I listen to good music, I disappear. Karl, 18

Laughter, a real belly laugh. Maria, 52

I draw, and that means a lot to me. Ingrid, 67

6,9

10 9 8 7 6 5 4 3 2 1 0

Over all

Total Perma score from the survey 7.8 Perma score for reference group Reference score for Frösunda’s administrative staff; read more on page 31.

RELATIONSHIPS are the strongest parameter among our customers, while engagement is the weakest.

NEGATIVE BAR Overall, the negative bar (N) shows a low level of things with an adverse impact on well-being. But it is worth noting that a small number of respondents have strong negative feelings: 25% score their loneliness at 7 or more 31% score their anxiety at 7 or more 17% score their anger at 7 or more

DREAMS OF A FAMILY Two years ago, Bilal Khadra completed his lonely journey from his childhood home in Algeria. He came to Sweden when he was 16 after two years on the street in Paris. “I slept in an abandoned factory. Those were not good times. I had no thoughts of the future. But people I met said I should try to get to Sweden. That I would get help, meet people who cared about me and be able to have a good life. And that’s what happened. Everything they said about Sweden was true.” BILAL CAME TO SÖRBACKEN, one of Frösunda’s homes for

unaccompanied adolescents. He found the support he needed there and feels he is developing. “Now I’m learning Swedish so I can train to be a chef. I’m keen and I’m able.” The first Swedish word he learned was “paltkoma” (“food coma”), followed by “lagom” (“just right”) and the phrase “alla ska med” (“all together now”). But he has learnt many other important things. “I have stopped taking drugs and I know more about the interaction between people. I think good relationships are based on honesty. Never pretending you care about someone when you don’t. I got that from the staff here at Sörbacken. I have taken those things to heart.” But it has not been easy. His experience of being a homeless refugee has left deep scars. “The street was a kind of school where I learned to read people’s feelings and motives. A person could be a friend one day and cheating or talking to the police for his own gain the next. I learned not to rely on anyone. Not even myself.”

“I learned not to rely on anyone. Not even myself.”

There are many times when he feels lonely. Memories of his childhood in Algeria are hard to bear and Bilal often finds it hard to concentrate. “My mum and dad represented two completely different paths in life. My mum loved me a lot. She used to say that I should do my best and be nice to other people, then life would be good. We were poor and we had nothing, but I got so much else. My dad did a lot of bad things, like selling drugs. He wanted me to work with him, dealing on the streets. Mum was completely against it. Their values were sharply opposed. That was before mum died …” Bilal, like the others in the home, is offered therapy aimed at managing his life and finding alternative strategies to destructive behaviour. They are all in great need of trauma therapy, but this type of dialogue demands more long-term treatment. Being forced to break off trauma therapy, e.g. if deported, can be devastating for the individual. Nevertheless, the past is always present in Bilal’s life. Both pleasant and terrible memories come back to him every day and cause pain. “Before, I couldn’t sleep and I didn’t understand why. I thought there were demons or something unnatural that wanted my body. I wanted four tablets but I was only given one.” Even in the daytime he sometimes wrestles with strong emotions. “I used to be really angry. Mad at everything and everybody. Nobody could calm me down and I didn’t want anyone to.

One day I was sitting in my room listening to music. Then there was a song that I associated with events in my homeland. I smashed everything in my room. It was late at night, but a member of staff took me in the car to McDonalds and we had a coffee there. And talked. Then I felt happy again.” Thanks to Sörbacken’s unique offer of therapeutic conversation 24 hours a day, Bilal has been given the tools to manage his situation. Although he still finds it hard to concentrate sometimes, he is a motivated student and has a plan for the future. “Previously when I was at school I sat there and thought about the past. I didn’t care about my grades or anything. Now I sometimes think I’d like to be a psychologist! First I’m going to be a chef and if I can concentrate at school then hopefully I’ll go on studying. Otherwise I’ll work as a chef.” The longing for a family is an important piece of the puzzle for Bilal. “I used to be sad when I saw families in town. It reminded me of my past. I wondered why other people were allowed live like that, with a mum and dad, but not me. Now there are a lot of people who like me, I don’t feel that way any more. I’m okay too. The staff here at Sörbacken look after me when I feel upset. They don’t leave me alone but spend time with me. They make an effort to understand how I am doing and what I am feeling. They give me hope and strength.” In the future, Bilal dreams of having a family of his own. “I want to teach my children not to make the mistakes I made, and I want to be good to them. I want to give them a secure life, a Swedish upbringing and teach them to be polite.”

Footnote: Bilal (we have not used his real surname) had his application for a residence permit rejected. He has appealed against the decision.

Bilal is now 18, and in his spare time he goes to the gym, boxes, goes to the cinema or plays pool. He has lived at Sรถrbacken for two years, where he gets help to manage his life despite his grim childhood memories.

QUALITY OF LIFE FOR EVERY INDIVIDUAL For Bilal, quality of life means the security to start his own family. The staff at the Sรถrbacken unit for unaccompanied adolescent refugees help him to realise his dream by helping him to notice advances he does not notice himself, for example. In the front pull-out, several customers talk about what quality of life means for them.

QUALITY THROUGH VALUEDRIVEN LEADERSHIP One customer who wants assistants to be silent and completely invisible. Another who wants them to appreciate and share his burning interest in dance bands. Individual care with respect, commitment and curiosity is the key to quality as experienced by the customer. To achieve this, every manager has to be a role model. The organisation’s culture is based on our core values and it is the responsibility of the managers to lead the way. IN 2013, CEO Susanne Sidén and HR Manager

Ann-Christine Kling travelled all over Sweden to spend a whole day with all of Frösunda’s 240 managers. They discussed Frösunda’s identity, history and future, and the leadership profile which describes the type of leader the organisation is looking for. “Frösunda’s managers should set the framework for their staff, be quality-conscious, business-orientated and good communicators. But above all, they must practise our values,” says Ann-Christine. “The managers are the key to developing the culture we want, where the whole organisation goes on improving the quality that our customers experience.” These days together are the first part of Frösunda’s major management effort. The fact that the organisation’s senior management have chosen to discuss values and behaviour in depth with all its managers is unique, and clearly shows the high priority that the quality work has within the business.

RESPONSIBILITY FOR HOW WE TREAT PEOPLE

One of Frösunda’s case managers is Emelie Hjelm Bonin. She manages the work at the Sörbacken centre, a home for unaccompanied adolescents with a particular need for care, support and therapy. As a manager, she is responsible for the way customers are treated in the business.

EMELIE HJELM BONIN, case manager, with Salem Ashk at the Sörbacken home

“I have met every boy at the door. Of course I spend a lot of time in the office, but you can’t just be that kind of manager here. I eat lunch with the boys and I am one of the adults they have in their network.” The staff at Sörbacken play a major role in the boys’ lives. They have come to Sweden without their families and do not have any network of their own. “A good manner means being so secure in your

professionalism that you dare to be personal. We have to be an extension of a mother, a sister or a cousin who cannot be here. I ask myself how I would like my children to be treated if I were forced to send them half way round the world to a foreign place where they did not know anyone. For me as a manager, it is a question of being clear about the sort of organisation I want to create and standing up for that.”

VALUES IN DAILY LIFE Frösunda’s core values, Respect, Commitment and Curiosity, hang on the wall of the office. Emelie and her staff have worked hard to put these words into practice. “This is the customers’ home. Not our workplace. We must keep that in mind all the time. It means, for example, that we must always say hello when we arrive and goodbye when we leave. They need to know who is in their home.” A good manner also means always putting the boys’ best interests first. “At my other unit there were boys who got up in the night to eat. The staff wanted to lock the door to the kitchen to stop them, but I made it clear that that wasn’t an option. Of course you can create a situation where few problems manifest themselves, but it makes it impossible to get to grips with the real issues. A boy who gets up in the night to eat does so because he can’t sleep. He may be lying there feeling afraid instead. It is a tough way to work but it is what I believe in. And it is my responsibility as a manager to run the business in this way.”

LEADERSHIP DEVELOPMENT CONTINUES Efforts to develop leadership within Frösunda will continue in 2014 and 2015. In the next stage, the focus will be on communication. This is part of the owners’ long-term strategy of focusing on quality, and the individuals in the business are the way to get there.

MEET FRÖSUNDA’S MANAGEMENT TEAM 9

3 5

11 7

FRONT ROW FROM LEFT: 1.ANNE-LIE GRANROTH Business Area Manager; internships in 2013: sheltered housing under the LSS; first job: nanny;

years in municipal services: 19, started work as a carer under the LSS in 1980. 2.JENNY MALMSTEDT Company Lawyer; internships in 2013: Panidon school, Dalagatan day centre; first job: intern at an embassy. 3. ANNIKA ERIKSSON Business Area Manager; internships in 2013: three day centres; first job: orthopaedic nursing assistant; years in county council service: 30 4. SUSANNE SIDÉN CEO; internships in 2013: Almen elderly care unit; first job: taking elderly people out as a summer job; years in the public sector: 7; years in health and social care: 18. 5.ANN-CHRISTINE KLING HR Director; internships in 2013: assistance in Gothenburg, elderly care in Blommelund; first job: sports consultant. 6.CHRISTINE ROSENCRANTZ Quality Manager; internships: Sörbacken Uppsala, personal assistant in Umeå; first job: nanny; years in municipal services: 20. 7. EVA MEYER Business Area Manager; internships in 2013: Wisborg home for unaccompanied refugee children, Almen elderly care unit; first job: building supplies; years in municipal services: 10 as a care assistant, 7 as a manager. BACK ROW FROM LEFT: 8.DAVID FREDRIKSSON Marketing and Business Development Manager; internships in 2013: PA and Dementia in Uppsala; first job: at sea. 9.HÅKAN HALLBERG Finance Director; first job: in a construction company; years in municipal services: recreation officer in his youth. 10.MATS PERNHEM Business Area Manager; placements in 2013: Ankdamsgatan unit and Dalagatan day care centre; first job: apprentice pastry chef; years in the county council: 2. 11.JAN-EMANUEL JOHANSSON Senior Advisor; internships in 2013: Höken, Stora and Lilla Edsvalla, Vårdsätravägen; first job: collective manager, Hassela Solidaritet; years in municipal services: 20; member of the municipal council.

A BURNING COMMITMENT TO THE CUSTOMER

“It was amazing. The CEO asked a lot of questions and reacted to what we said. She listens, and I think it will lead to changes.” SELVER ADEMI, 18, WHO LIVES AT THE PANDION HOME

FOCUS ON THE CUSTOMER AT ALL LEVELS For Frösunda it is natural to talk to customers – in the units, in our quality work and at senior management level. It is a way of practising what we preach, making use of our customers’ resources and learning from their ideas and reflections. Frösunda’s CEO Susanne Sidén has her own meetings with customers from all four business areas every quarter, which gives her a unique insight into the business and the situation of our customers. “It is good that Susanne makes time for this. She is a top boss and it is good to be able to tell her directly when something is not working. If I told someone else, they would all censor it and it would never reach her,” says Christoffer Wirenblad, who is 30 years old and lives at Frösunda’s only treatment centre for adults, Villa BoCilla near Gävle. “I think it’s good that the CEO meets customers – provided that it leads to changes or we get an explanation of why there can’t be any change,” says Oskar Petterson, 18, who lives at the Pandion home in Linköping. The meetings are a way of checking that the continuous improvement work is reaching our customers. It is a statement of the fact that the whole Frösunda organisation is there for the customers. 22

THE CONFIDENCE REPORT IN FIGURES, 2014 A YEAR AGO, we started work on a new quality organisa-

tion. Focusing on the customer throughout the process, we have made changes. Our customer surveys show that our efforts are on the right track. But it is not enough. We still have plenty of room for improvement, both organisations like ourselves and the sector as a whole. Now we need to start talking quality: for real. And that means touching on subjects that are hard for us, like municipal funding. How can we maintain decent health and social care with increasing costs? This question is especially relevant in smaller municipalities where an ageing population has to be looked after by a diminishing number of people in work. I am convinced that we can help the municipalities through innovation in our activities. Individualised health and social care is the key, enabling us to base our quality offering on the individual customer’s needs and

according to the aims and objectives defined in the specific support decision. Customers have a right to live their lives according to their own standards and values. Together with the customers, we need to create the conditions for this in order to set the foundation for the care system of tomorrow. We also see it as an important part of the solution to future challenges. Finding good tools and methods for following up on an individual request is a challenge, but it is a challenge we are willing to take on with various customers. We base this on the fact that it is the customers who tell us about quality. We have to start research, set ambitious goals, develop good tools to monitor the quality as perceived by our customers and demand action where there are shortcomings.

“Now we need to start talking quality: for real.” CHRISTINE ROSENCRANTZ QUALITY MANAGER

We are starting with ourselves and inviting our stakeholders – clients, the IVO, sector organisations and customers – to join us.

QUALITY MEASURES 2013 Monthly follow-up of deviations in health and social care from the operations to senior management Peer controls in all areas Internal inspections within all units in the Individual and Family business area in Sweden Six-monthly follow-up of all units taken over Staff survey Pilot and develop new types of customer survey

MAJOR EVENTS IN THE YEAR Frösunda has done what we set out to do in the first year with the new quality organisation. Again and again, we have been supported in our belief that satisfied customers make for proud and committed employees. The importance of local management has been highlighted by our investment in leadership development. Work on implementing our core values across the organisation has progressed.

PRIORITIES FOR 2014 • Develop process control • Produce local management systems • Continue development work on customer surveys • Run two “mystery shopper” projects • Introduce a quality committee • Leadership development

TRUST IN FRÖSUNDA A policy alone does not create trust – it is the people, their manner and deep respect for the customer’s feelings that do that. Frösunda’s quality policy is the map that guides us, helps us understand where we are going and tells us when we get there. FRÖSUNDA ADOPTED the quality policy in 2012, and in

2013 we carried out a number of activities as well as updating procedures and management systems. We can look back with pride at the progress we have made in the first year, and forward with humility to the journey that lies ahead. Our shared goal is to be the obvious choice in the Nordic region and a role model for how social care can be provided in a responsible way and with high quality. We will get there by focussing on our customers and always being true to our mission: We earn trust by taking responsibility. Our responsibility is to the customer. Always. Our work is based on the laws that govern health and social care and on methods built on research and evidence. The framework is established in agreements with the paying customers, then there are the values that arise from our customers’ individual needs and wishes. We have three goals for our activities: customer satisfaction, contractual performance and regulatory compliance. CUSTOMER SATISFACTION means ensuring that custom-

ers get the health and social care that they need and want, to experience the best possible quality of life. What constitutes quality of life for any given customer is an individual thing and needs to be described in a personal action plan. 24

CONTRACTUAL PERFORMANCE means that we fulfil our agreements right down to the smallest detail. Our clients should be able to rely on Frösunda.

That does not mean that we cannot make mistakes, but we always strive to prevent or, in the worst case, rectify errors in the fastest and best possible way. REGULATORY COMPLIANCE means that we obey the laws

and regulations that govern and guide us. Internal and external inspections ensure that we provide safe and effective care.

OUR MANNER – THE KEY TO OUR IMPROVEMENT WORK Most of our improvement work is about our manner and approach – how we act towards our customers. Our values are expressed in our behaviour in the many meetings with customers that take place every day, andthat is where our quality comes through. Changing values is an arduous exercise, even for those who are highly motivated. So we need to recruit employees who share our values – respect, commitment and curiosity. We also need to ensure that our actions match our values, such as when we take over existing operations. When our expectations of each other are clear, both managers and staff feel comfortable. The managers need clear tools to train, develop and where necessary correct the behaviour of their staff. Then the work of the staff will be clearer and simpler, and the focus will be on the most important thing, which is what happens in encounters with customers. This is a continuous improvement effort which demands close collaboration between Frösunda’s support functions – Business Development, HR and Quality

Management – and business areas – Personal Assistance, Disability, Individual and Family and Elderly Care. Then we can work together throughout the organisation to add value for every customer. That gives us a big edge over our competitors. In 2013 we tackled the major challenge of strengthening the management across the entire organisation and there is a clear expectation of how the work should be done. The tradition in the health and social care sector is more a “free choice of work method”, but we are developing an idea of how we should work to deliver care to every individual.

QUALITY AS THE CUSTOMER WANTS IT We know from experience that there are three factors that are crucial to quality as perceived by our customers. AVAILABILITY means being accessible to customers in a way and at times that suit them. SECURITY is created by maintaining and reinforcing all types of continuity in all aspects of our work, such as personal contacts, times and documentation, and ensuring that any tools work. TRANSPARENCY means that clients, customers, and carers should know what to expect of us in any given situation. It means that we own up to the errors and deficiencies that may arise and are open about the results of actions taken and our findings from internal and external controls.

Continued on page 26

The quality triangle

CONCEPT WITH FLEXIBILITY

TOWARDS THE QUALITY GOALS: Extra high customer value

h ac pp ro ic a en tog

n pe

do ip rsh

lea

Sa lu

Added-value according to customers’ needs and wishes Extra high, specialised expertise

ble ha

o pr Ap

>90% CUSTOMER SATISFACTION 100% CONTRACTUAL PERFORMANCE 100% REGULATORY COMPLIANCE

We design our offering based on our customers’ wishes so that every aspect of the work adds the greatest possible value.

MINIMUM LEVEL

Management systems Basic care as per decision Evidence-based methods

We do not enter a procurement procedure if we believe the conditions will not allow us to deliver at least this level of quality.

Value-driven behaviour Respect, Commitment, Curiosity

OUR MISSION

OUR QUALITY GOALS

We earn trust by taking responsibility Customer focus

90% customer satisfaction 100% contractual performance 100% regulatory compliance

NKI – SATISFIED CUSTOMER INDEX

91% Partial survey; read more on page 31

91% 72%

75%

25 Average for health and social care organisations

Frösunda 2011

Frösunda 2013

CONFIDENCE REPORT Our systematic improvement work is based on the provisions and general guidelines on management systems for systematic quality work (SOSFS 2011:9) from the National Board of Health and Welfare. The confidence report marks both the end and the beginning of the quality year. All the year’s activities are driven by the same thing – customer-focused quality work. Based on the senior management quality policy, in the form of goals and KPIs, every case manager is responsible for producing an action plan. In the next step, goals and activities for their unit are linked to the employees’ individual targets. There is a clear link between the preceding follow-up work and the actions and initiatives described in the plan. The task of the case manager is to make a plan that is based on the needs of the individual unit while safeguarding quality and improvement work across the organisation. The goals and associated KPIs are checked every month and compiled by the Business Area Managers. For the CEO’s monthly review of each business area, there are two standing agenda items – finance and quality.

The quality committee: the committee is headed by a case manager or regional manager and encompasses different professional categories. It addresses any reported deviations, complaints and comments and drives the continuous improvement work. It gathers knowledge of the quality of the activities by monitoring data in the quality register and running open annual comparisons. At every workplace meeting there is an agenda item for the quality committee to discuss and make part of the quality work. Peer controls: Peer controls are a way of following up our own activities by way of a learning discussion between case managers, providing a tool to further improve risk analysis and make constant improvements. Quality register: Frösunda actively records our work in the quality registers that exist today: Senior Alert, the Swedish Palliative Register and the BPSD dementia register. Journal reviews are an important part of Frösunda’s quality monitoring. Experts from the Quality department review 15% of our customers’ journals every year and contribute suggestions for improvement. Deviations in health and social care: Frösunda places great emphasis on documenting deviations, which both provides information directly to the business and helps us to develop procedures and instructions.

MANDATORY QUALITY ACTIVITIES

In our day-to-day work we have a number of mandatory activities in the units that support customer-focused quality work at all times; in other words, our improvement work.

Comments and complaints: Anyone affected by Frösunda’s activities can lodge a complaint or make a comment which will be followed up as part of monthly reporting.

Self-assessment: We use self-assessment to identify strengths ad weaknesses in the business and analyse delivery reliability based on Frösunda’s three quality goals.

THE QUALITY DEPARTMENT The Quality department is part of Frösunda’s value creation chain and is responsible for analyses and overall improvement work.

Apart from monthly quality monitoring, the Quality department takes targeted action to establish whether there are random errors that have to be addressed directly or systematic faults that need to be remedied by developing processes or procedures. The overall analysis also involves monitoring how well the goals have been reached and whether they have led to higher quality – in other words, whether the sum of all the goals has resulted in better customer satisfaction, contractual performance and regulatory compliance. External inspections: All activities are subject to external inspection. The outcome is generally published. Frösunda follows closely which aspects are considered especially important by the supervisory authority and incorporates these into our self-assessment work. Internal inspections: Based on the knowledge gained from external inspections and self-assessments, the Quality department carries out targeted analyses and in-depth studies based on materiality and risk. Internal inspections are mandatory when a unit is started up or taken over. External audit: Every year an audit is conducted by an authorised and independent auditor in accordance with the ISO standard in those units that are ISO-certified. The audit looks at how well the unit complies with processes, procedures and our quality management system. One sheltered housing unit, one day centre, one residential home and one assistant’s office are currently ISO-certified. They act as role models for the others. Mystery shoppers: Anonymous people whose job is to phone and visit Frösunda units including the head office, board and owners to check availability, treatment and compliance with our processes. In other words, to test whether the behaviour we strive for matches what we do from day to day.

The CEO’s customer groups Frösunda’s CEO meets customer groups from each business area four times a year. The aim is to find out whether our continuous improvement work is reaching our customers.

Value-adding Quality in two directions Arrows back to business areas fix random errors Arrows forward to business areas structural development

Frösunda adds value in society and within the organisation by always focusing on the customer and customer-defined value. The budget is the wheel that turns and makes the whole value creation process possible.

Customer Ombudsman: Frösunda’s Customer Ombudsman operates independently and reports directly to the CEO. The Customer Ombudsman personally ensures that any matter is addressed quickly and provides feedback to the person who raised the issue within 24 hours.

Finances

Elderly Care

Individual and Family, Sweden

Business development

11% 58%

Personal Assistance

Customerdefined value

26%

Disability

Quality

HR Customers

2,432 CLIENTS

Present in 62% of Swedish municipalities

Assistance Greatest

Disability Cutting edge

Individual and Family Development

Elderly Care Growing

2013 DEVIATIONS IN HEALTH AND SOCIAL CARE 2013

Step 1: Classification

LSS

Assistance

Elderly Care

Individual and Family

Total

Work procedures

141

186

Manner

Criminal offence

Documentation

Case

110

113

234

Information/communication

136

161

Information transfer

Action

328

351

Medicines/aids

192

299

Care

117

Violence and assault

203

246

Care and treatment

Care-related infections

Total

1,128

111

240

220

1,699

Step 2: Impact on the customer

LSS

Assistance

Elderly Care

Individual and Family

Total

No known injury/health risk/problem situation

698

199

176

1,124

Risk of injury or problem situation

268

368

Extra supervision/monitoring

228

245

Hospital treatment

Injury requiring treatment

Total

1,248

240

220

1,801

Step 3: Organisational risk

LSS

Assistance

Elderly Care

Individual and Family

Total

No risk of recurrence

185

281

Risk of recurrence

894

197

203

1,343

Total

1,079

240

220

1,624

Step 4: Lex Sarah

LSS

Assistance

Elderly Care

Individual and Family

Total

Number of “Lex Sarah” reports

“Lex Sarah” reports to IVO

DEVIATIONS IN HEALTH AND SOCIAL CARE Frösunda attaches great importance to documenting deviations. This procedure is a recurring topic in workplace meetings, to keep it fresh in people’s minds. The case manager grades the deviation in three stages and also decides whether they may point to serious problem situations. The deviations are also followed up by the Quality department, to ensure that procedures and instructions are constantly improved using the knowledge gained from deviation monitoring.

FEWER LEX SARAH 2014

2016

With improved and enhanced procedures for deviations in health and social care, we expect to see an increase in the number of reported deviations in the short term.

When deviations in health and social care are reported quickly and early, this results in improved procedures and greater knowledge of the risks throughout the organisation. We can pick up and prevent risks, which will lead to fewer incidents. We see the results of the improved quality in fewer “Lex Sarah” reports.

PATIENT SAFETY REPORT SUMMARY FOR 2013 THE PATIENT SAFETY REPORT is prepared every year and covers special housing for the elderly and persons with physical and mental disabilities. The full patient safety report can be found at frosunda.se.

MAJOR ACTIONS IN 2013 The work of drawing up procedures for patient safety continued in 2013. These are available in the management system. During the year, the chief medical nurse (MAS) carried out inspections and a quality review. Frösunda’s dietician implemented the action plan for food and mealtimes and the care program to prevent undernourishment. All authorised staff, including agreed sub-contractors, document the situation in the electronic patient journal Safedoc. Training activities concerning patient safety issues are going on all the time, and development of interactive online training has started. The Quality department has recruited an expert to help implement the “My” method within elderly care. The method contributes to patient safety by means of a salutogenic way of working. Comments from customers and carers have a major bearing on the patient safety work. Among other things, this is supported by clear procedures for customers, carers and staff when it comes to reporting deficiencies, comments and complaints. Authorised staff contribute to increased patient safety by reporting risks, incidents and negative events, i.e. health and social care deviations. They also participate in investigation and analysis work and in assessing risks in terms of patient safety. Frösunda continued to introduce quality committees in 2013, as an aid to local quality work. Experts and the chief

SERIOUS PROBLEM SITUATIONS AND SERIOUS BREACHES OF CARE medical nurse from the Quality department play an active role in investigating reported serious incidents and breaches of care. OVERALL STRATEGIES 2014 For elderly care units, work is on-going to turn national guidelines for dementia patients into structured personcentric working methods. The salutogenic approach and manner of the staff will be developed and qualityassured. Work is on-going to draw up Frösunda’s programme of health promotion and function retention work in elderly care. This includes both physical and social activities. Cooperation with relevant medical practitioners in elderly people’s accommodation will be pursued throughout the care chain to promote patient safety. This applies especially to the area of medication and care at the end of a person’s life. For end-of-life care, we will continue to implement the evidence-based and approved standard care programme called the Liverpool Care Pathway. For all special housing, development of patient journals in Safedoc will continue. Recording and documentation under the Health and Medical Care Act (HSL) will be developed using the national glossary for health and social care, the ICF and the National Board of Health and Welfare classification system (KVÅ). Increased cooperation with carers and principals responsible for home and primary care where Frösunda does not bear the responsibility itself. Our internal procedures should be quality-assured to highlight and analyse risks associated with health and social care provided by Frösunda staff on behalf of others.

LEX SARAH is part of the Social Services Act (SOSFS

2011:5) and the Act on Support and Service for Certain Persons with Disabilities (LSS). It states that employees must report any problem situations and risks, that the person running the business must investigate, remedy and report any problem without delay, and if the problem is serious, report it to the IVO. In 2013 there were 21 “Lex Sarah” reports from Frösunda employees to their case managers. Of these, four were so serious that they resulted in “Lex Sarah” reports to the IVO. LEX MARIA is part of the provisions in the Patient Safety Act (2010:659), and states that the carer must report any incidents that caused or could have caused serious breaches of care to the IVO. Health care and medical staff are required to contribute to a high level of patient safety by reporting risks and incidents. The care provider must investigate and establish the sequence of events and take steps to prevent similar incidents or avert the risks. The IVO will ensure that the care provider has taken the action required for a high level of patient safety.

PILOTS OF NEW CUSTOMER SURVEYS In 2013 Frösunda ran several pilots as part of the effort to develop customer surveys, and this year for the first time we ran surveys in all our target groups – customers, carers, clients and internal customers. WELL-BEING SURVEY Earlier in this confidence report, we reported on the quality of life (well-being) survey “Perma”, for which we are using the latest research to find ways of measuring how well we are doing our job. The pilot well-being survey was conducted on all customers within the Individual and Family business area. As we are the first people in Sweden to pilot this survey, we also ran a survey on our own administrative staff to obtain a reference value for the customer survey. Capturing well-being is complex, but in the pilot we saw great potential in the method and we will extend the pilot in 2014. The investment in the well-being survey is part of our research and development: it is a long-term project to find precise measurements of the value we are actually aiming for, which is quality of life as perceived by the customer.

Perma well-being survey Total Perma, Individual and Family customers

Curiosity

66%

26%

8 6

CONTRACTS WON

The proportion of public contracts won gives an indication of how satisfied our customers (i.e. the municipalities) are with Frösunda. And an even better indicator is when the customer opts to continue working with Frösunda. One of Frösunda’s contracts was up for renewal in 2013, and we were trusted to continue.

2 0

84% NNI

65%

Frösunda tested various tools for measuring contractual performance and regulatory compliance in 2013. These included assessments of inspections carried out by the IVO. The measurements will be implemented in the new management system in 2014.

Our large-scale customer satisfaction survey was conducted on customers in the Disability and Personal Assistance business areas. The work started with a dialogue with customers and carers about the questions. We then piloted a questionnaire based on our values – respect, commitment and curiosity – and a binary scale (yes or no). We also piloted three different distribution methods for the questionnaires – electronically, on paper and by telephone. Commitment

P – Positive emotions E – Engagement R – Relationships M – Meaning A – Accomplishment O – Overall N – Negative feelings H – Health L – Loneliness

Total Perma, Frösunda administrative staff

6.9 7.8

Customer satisfaction based on values

Respect

CONTRACTUAL PERFORMANCE AND REGULATORY COMPLIANCE

91%

Respect

Commitment

Curiosity

NKI

92%

89%

92%

Satisfied carer index For the first time, we ran a customer satisfaction survey for the customer group “Carers”. The pilot was run with carers within the Disability, Personal Assistance and Elderly Care business areas.

69%

Availability and manner

Satisfied internal customer index In 2013 we ran our first ‘Satisfied internal customer survey’. An analysis of the responses shows that communication is the biggest area for development. There also seems to be a mismatch between demand and supply, which is also likely to be due to communication. So we need clarity about expectations.

Skills

Reliability and delivery

68%

NIKI

65%

66%

69%

PERSONAL ASSISTANCE

100%

DISABILITY

36%

INDIVIDUAL AND FAMILY

25%

ELDERLY CARE

100

NET PROMOTER SCORE

SEK BILLION TURNOVER

Reasons: Excellent performance from case manager, longstanding relationship with the organisation, managers and personal assistants

10/10

I November, the West region ran a pilot to measure the net promoter score (NPS). The survey identifies “promoters”, who would recommend Frösunda to others, “passives”, who are satisfied customers, and “detractors”, who are dissatisfied customers. The NPS is expressed as the percentage of promoters minus the percentage of detractors. The survey is meant to give the business a tool to turn dissatisfaction into customer satisfaction. Large differences were revealed at an office level, and hence great opportunities to identify and disseminate success factors. The two most important factors for the NPS turned out to be the responsiveness of the case manager and the ability to find substitute assistants. The NPS for the West region is 26%.

2.8

Promoters: 135 customers gave Frösunda 9 or 10

282

Reasons for not giving the highest marks: Hard to find substitute assistants, sometimes lengthy waits to get in touch, feeling that Frösunda does not provide local support

8/10

7/10

ISO-CERTIFIED UNITS

Detractors: 62 customers gave Frösunda 6 or less

6/10

Reasons: Difficulties in finding substitute assistants, long time to respond or take action, high staff turnover or absence through sickness

5/10 4/10 3/10 2/10 1/10

EMPLOYEES

All residential homes, Individual and Family Mystery shoppers Reviews of documentation within Assistance Review of compliance with the Health and Medical Care Act Quality audits for the patient safety report Contract follow-ups

Passives: 85 customers gave Frösunda 7 or 8

9/10

8,286

2013: INTERNAL INSPECTIONS

Gender breakdown: senior management

Frösunda ISO-certified two new units in 2013, Brolunda sheltered housing and the Sörbacken residential home. The Dalagatan day centre and Växsjö assistance office were already certified. These units are leading-edge models that set the standard for other units and they will be of great benefit in 2014 as we start work on the local management systems. Frösunda is not planning any more ISO certifications in 2014, but will certify an elderly care unit under its own management in 2015.

LSI – Leadership index

Men

36%

29% 71%

% of turnover

No. of employees 64% Individual and Family 9%

Disability

Gender breakdown: group

1118

18%

Women

Individual and Family 388

Elderly Care 168

Average for businesses in the service sector

71%

74%

75%

Frösunda 2011

Frösunda 2013

NMI – Satisfied employee index

Men

36%

29%

Elderly Care 2% 32

85% Personal Assistance 71%

64% 6384 Personal Assistance

71% Women

Average for businesses in the service sector

91%

92%

Frösunda 2011

Frösunda 2013

LEX SARAH& LEX MARIA REPORTS Activity

Reports 2012 2013

IVO notifications 2012 2013

Lex Sarah Personal Assistance Disability Individual and Family Elderly Care

4 43 0 0

4 1 2 14 11 1 1 0 0 2 0 1

Lex Maria

Total

47 22 12 5

PEER CONTROLS Peer controls are a new quality tool for Frösunda. The aim is to create a platform for learning and development between colleagues. Case managers met in pairs for a learning discussion using checklists. On the first occasion, in October 2013, the discussion focused on three topics – documentation, management systems and deviations in health and social care. Peer controls are a tool for analysis and development work. The results are reported to the Quality department, where they are analysed and used for operational and business planning.

To check availability, manner and processes, anonymous persons called Frösunda’s units, including head office, 634 times between March and June 2013. 49% of the calls were not answered, with a relatively low score for availability and feedback of 3.65 out of 5. This is Frösunda’s biggest area for development. When the right person answers, the score is very high, 4.75 out of 5. The average score for communication is 4.76, and for information 4.73. Frösunda’s emergency number (the Central Crisis and Staffing line) had 100% availability and the highest score across the board.

16 14 12 10 8

“The word ‘control’ could easily be considered severe, but being able to sit here with a colleague is a positive thing which has helped me to learn a lot.”

6 4

ANDREAS ALBANESE, CASE MANAGER FOR KAVELDUNET AND TENSTASTRÅKET SERVICED HOUSING

MYSTERY SHOPPERS

Peer controls in three areas %

2 0

Social documentation

EXTERNAL MONITORING External inspections are conducted by the IVO and the Swedish Schools Inspectorate. Frösunda underwent 36 inspections in 2013, 12 of which led to action being taken.

Types of measure, percentage and area 2% Real Estate 27% Organisation

Individual 40%

73 % 95 % Availability and feedback

Manner and processes

31% Structure

Deviations in health and social care

Management system

Examples of inspection files at the IVO. 9.1-19301/2010 9.110044/2012 9.1-28560/2011 9.1-48851/2012 8.4.2-12382/2013 701-8873-07 9.1-9557/2011 9.1-13902/2011 9.5-25186/2012 9.1-48511/2012 9.1-5448/2011 9.1-28811/2012 8.4.2-43530/2013 9.1-18897/2012 9.1-54595/2012 9.1-42870/2011

8.2-28127/2013 8.2-43757/2013 8.2-1277/2013 9.1-9909/2011 9.1-5474/2012 9.1-39175/2011 9.1-24264/2012 9.1-48902/2012 9.119134/2012 9.1-19134/2012 9.1-48471/2012 8.5-34971/2013 9.1-9519/2011 8.2-1277/2013 8.2-1277/2013 8.5-15712/2013 33

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Frösunda Frösundaviks allé 15 P.O. Box 708 SE-162 72 Solna +46 (0)8-505 23 500 www.frosunda.se If you have any questions about our quality work or the confidence report, please contact our Quality Manager, Christine Rosencrantz. e-mail: christine.rosencrantz@frosunda.se, tel. +46 (0)10-130 31 53

Content production: Lumen Behavior Design: Pondus Kommunikation Cover photograph: Andreas Nilsson Other photos: Johan Spinell, Johan Granstrand, Johanna Hallin, Mikke Hedberg, Niklas Ehlén 3D graphics: The Core Printing: Joma GP, Ljungby 2014

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THE QUALITY PYRAMID It is the responsibility of the Quality department to drive the on-going work to deliver the highest possible quality in the health and social care that we offer our customers. In one sense, working on quality is automatic and part of our core process. But it is also about changing people’s behaviour and using customer perceptions to improve quality. The quality pyramid shows how this works – with supplementary perspectives and a constant base. The first side of the pyramid describes the customer perspective. At the base are decisions that affect the customer. This is then built on with the aim and purpose of the client, the paying customer, in taking the action. At the top are the customer’s own wishes for optimal well-being. The second side of the pyramid describes delivery. At the bottom are our attitude and manner, plus acts, ordinances and regulations. Above these are policies, processes and procedures; leadership, skills and staffing. At the top is the best possible knowledge and our efforts to understand and implement new findings in the business. The third side of the pyramid describes our control and monitoring. At the base are internal controls, together with supervision and inspections carried out by national control bodies. With these we group groupwide controls, peer controls, the satisfied employee index and key indicators. Right at the top of the pyramid is the satisfied customer index.

personer med funktionsnedsättning [Conditions at work: a study of discrimination in the labour market and the situation of people with disabilities] . Statistics Sweden (SCB): Stockholm, 2013.

The quality pyramid

WE EARN TRUST BY TAKING RESPONSIBILITY

Care for the highest quality of life. Whatever it takes.