Guest Post – Ali Damji (Canada): Asylum Centres in Sweden – Where Politics Meets Health

Rudolf Virchow once famously said, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution”.

That close intertwining between politics and medicine is a huge interest of mine, and in part, contributing to my study visit in Sweden. Not only am I interested in learning about quality improvement but also the policy levers which can improve the lives of patients powerfully.

Last week, I had the opportunity to work closely at that intersection with one of Jonkoping Region’s newest nurse-led teams called the Health School. This team works solely with asylum seekers in the region by providing onsite group education at Asylum Centres on:

  • Accessing the Swedish healthcare system
  • Self-care at home
  • Coping with stress, sleeping, anxiety, and PTSD in a new country while waiting for a decision regarding a claim
  • Having an opportunity for group or one on one counseling with a kurator. Kurators provide mental health support and counseling and are part of the health and wellness circle of mental health care.
  • Healthy behaviour training such as smoking cessation, reducing alcohol intake, exercise training, and appropriate nutrition.
Sample advertisement for the Health School. It is also written in the language of the population they are reaching out to.

Since the members of the team are trained nurses and a translator, the Health School visits also function as an opportunity for asylum seekers to start a conversation with a healthcare professional about any individual health concern following the session. I witnessed patients bringing forward their medical concerns and receiving an assessment onsite, or getting their care coordinated so they could be seen by an appropriate professional (e.g. GP for getting a diabetes medication assessment) the same or next day. Thanks to a shared EMR, electronic medical records and consultation requests can be filed right on site from the asylum centre using a laptop.

A novel approach of using technology to connect asylum seekers with local Swedish people and getting started up in a new place. 

From the political side, Europe is in the midst of a large influx of refugees and asylum seekers fleeing conflict. Sweden has historically been one of the shining examples of acceptance in this regard, taking in more refugees and asylum seekers per capita than almost any other country in Europe.

So from what I saw, how are asylum seekers treated in Sweden? If you’re unfamiliar with the term, asylum seeker refers to an individual who has fled to another country, but is not a refugee and therefore has not been officially accepted into the country. However, they are able to stay in the country until a decision is made regarding their status – either they will be able to immigrate or they will be sent elsewhere. Sometimes these claims can take over a year.

While I was with the Asylum Health School team, we visited two asylum centres. These are often repurposed buildings that provide food, lodging, and shelter to asylum seekers as they wait for their claims to be processed. The facilities can vary but generally they are private facilities that contract their services to the government, and are inspected by the Immigration authorities in Sweden.

Asylum seekers receive certain healthcare coverage while in Sweden. All emergency or acute care services will be provided to them if needed, including access to a primary care physician. However something that is not as medically urgent will not be covered such as rehabilitation services until they receive a permit to stay. Schooling to teach children English and Swedish is provided as well, but until the claim is processed they cannot register in a formal schooling program. There are still user fees for asylum seekers but they are less than the Swedish population. It costs approximately 50kr ($7.50 CAD) for an asylum seeker to receive primary care for example.

The issues surrounding migration, refugees, and asylum seekers is one of deep personal significance to me. As a young child my mother and her entire family fled Uganda as refugees under the regime of Idi Amin. They were accepted as refugees in the UK and eventually emigrated from there to Canada where I have had the privilege of growing up. Without accepting policies, it’s quite possible I would not be writing this blog today.

In an era with unfortunately, an escalating rhetoric of misconceptions, fear, hatred and bitterness towards refugees and asylum seekers who are forced into challenging situations due to political circumstances beyond their control, I was proud to see the acceptance and support that Sweden has extended to its asylum seekers, even though its system is becoming increasingly overstretched. It is reflected in the actions of people too: ordinary retired citizens in Sweden volunteer their time to help asylum seekers learn Swedish for example.

I was utterly impressed by the Asylum Team’s novel work too, which is making people feel welcome in a new and strange and different country with a very different healthcare system.

Most inspiring however, was an encounter at one Asylum Centre and its manager. The manager was living in a facility like this himself and after becoming a permanent resident returned to work at the centre. There, he runs program for the asylum centre residents, sometimes using his own money to pay for additional dinners or outings for the residents if the budget has been used up. He also runs activities for them such as a football (Soccer for my North American friends) league that provides a familiar pastime. When I asked him why he was doing this, he responded simply that he remembered when he was in their shoes, and knows these small things make such a big difference.

“So what if it costs a bit of money for me, it is worth it to make them feel welcome in this country while they are dealing with so much stress.”

As my study visit winds down and I prepare to head back to Canada this week, it was this moment of compassion that reminds me why I decided to engage in this work in the first place. Quality improvement and policy are levers, and medicine is an art and science, but they are fuelled by compassion and a love for humanity. No matter the pressures, we mustn’t lose sight of that love and the ties that connect us with one another. And that gives me strength to continue to improve my system and care for my future patients when I get back home.

Yet another Swedish fika! A Cinnamon bun! Got this one in Gothenburg! (There is a giant variety that you can buy in Gothenburg but I was not brave enough! Something for the bucket list next time!)


Till next time,




Guest Post: Ali Damji (Canada) – Working Together: What can we learn from Jonkoping?

My last blog post focused on how providers can better work with patients and how Jonkoping is showing some considerable success in this regard. This post will focus on how providers can best work with one another, specifically from what I witnessed in primary care.

I recently had the opportunity to experience Oxnehaga Primary Care Centre, located in a smaller suburb within Jonkoping with a larger representation of low socioeconomic status, new immigrant and refugee populations. Here are some of the highlights.

What’s with the bubble? When you arrive, you take a number and for privacy you enter and speak with the receptionist when your number is called. This protects confidentiality in the waiting room.

Funding: All practices receive a budget from the region based on how many patients they have. There are premiums for both socioeconomic and medical complexity. Using this budget, the providers must work with administrators to manage the budget and ensure that the primary care centre does not run a deficit. This budget also pays all of their salaries. Notably, tests and investigations lead to more expenditures, so these must be ordered judiciously.

Labs are onsite in the primary care unit. This allows blood tests to be taken and interpreted quickly on site (typically within 10-15 minutes). This allows patients to avoid needing to come back for unnecessary repeat visits and get an answer quickly for common tests.

Clear Intake Processes: To come to the primary care unit, almost all patients will call in advance. There are always 2 nurses running phone booths in the office on a rotating shift schedule. If there is a wait to have your call answered, the patient can request a call-back time. Some patients can choose to come in for a drop-in appointment but they often will need to wait or hope there is an opening. Once the patient has been assessed over the phone and needs a visit, the nurse will book them into the schedule for the most appropriate provider (usually a nurse). Same day and next day appointments are common. If it is something that the patient does not need to come in personally for (such as a medication renewal that is more benign), the nurse will flag this in the appropriate person’s calendar and schedule a time for that task to be completed that day.

Possible direct pathways to the right provider for a patient in primary care. Decided by the nurse.

Who sees the patient first? This is up to the nurse on the phone. Typically it is a nurse. There are a wide variety of specialized nurses in areas such as Heart Disease, Asthma, Diabetes, Smoking Cessation, Incontinence, Care of the Elderly, Care of Children and Hypertension. These nurses are able to see patients independently, make basic medication changes (e.g. encourage patients to take medications twice or three times per day on same dosage), interpret labs and tests such as spirometry and ECG, and consult other services. They cannot prescribe a new medication nor order tests. But if the patient needs a drug or test they can either directly ask a physician or “Distrikt Nurse” (similar to Nurse Practitioners in Canada) to see the patient that same day by pulling them in from the hall, or they can place the order in the EMR and send an instant message for the other practitioner to sign during a free moment.

Meet Diagnostick. This device when grasped behaves like a one lead ECG. Patients can receive a device from the centre on loan and can use this when they feel their heart racing. The data can then be transmitted right into the EMR digitally at the next visit. Useful for those patients who are fine in the clinic but have arrhythmia at home! Nurses coordinate and interpret the results from this and consult when necessary.

Informal Consults: Hallway consultations are very common. If a nurse is assessing a patient and wants a physician to lay eyes on the patient, they will quickly see if one is available to come into the patient room, and then continue managing the care of the patient unless it is something significantly complex or acute that requires a formal transfer of care. Similarly if a mistake was made and a patient was inappropriately assigned to a nurse but requires a physician, the team works together informally to make sure the patient is seen the same day by the physician. These informal consultations exist across all the services offered in primary care.

Physiotherapy in Primary Care: In Sweden, physiotherapy is part of universal health care. There is abundant evidence that exercise is one of the best treatment modalities for low back pain and should be a first-line treatment before medications. In Jonkoping, a patient presenting with low back pain or most MSK concerns will be booked into the physiotherapist’s calendar by the nurse through the process mentioned above, and may not ever see a physician. Patients even have the option of calling the physiotherapists directly during certain hours. The physiotherapist will work with the patients to teach them exercises in an on-site gym and see them in the gym regularly. Patients can even purchase a temporary membership if desired. If the patient is unable to control the back pain, then a family physician can become involved as a consultant to assist with medications. This is the case for not just back pain, but many chronic and acute musculoskeletal diseases. Physicians will also become involved in medical complexity arises (e.g. fever with back pain, red flag symptoms etc).

On-site gym at the primary care centre. Also can be used by med students!

Physicians: The physician resources in the primary care centre are reserved for diagnosis and management of complex medical patients. Every 2 years every patient with a chronic illness will be seen by the MD for a complete exam. This type of model makes sure physicians are utilized for the patients that need to be seen by them.

No escaping the white scrubs! They are required uniform in primary care units too. All staff have the same ones but can be distinguished by badges. All for infection control! 

Technology: The shared EMR is crucial in supporting this environment. All notes, tests, and investigations are on the same EMR and this is also true for specialist consultations and care received anywhere in the region. This enables all members of the team to be aware of how patients are doing, without necessarily seeing them in person.

Culture: This is often something we take for granted but “the small stuff” really does matter. There is no hierarchy from what I could see in this system. Nurses, doctors, physiotherapists, administrators, social workers, and kurators all eat lunch and Fika together, are dressed similarly, and address one another by first name. Not knowing someone’s name who looks after your patients is unheard of. There is respect for one another’s scope of practice and no “turf war”. Physicians feel relieved that RNs and physiotherapists see more of the chronic patients so physicians can focus on the more medically complex ones that their training is best suited for. This isn’t just a primary care phenomenon. I’ve noticed this in the hospital too where there are nurses who have been trained by physicians in endoscopy and now complete almost all routine screening colonoscopies, leaving the GI doctors and surgeons to focus on more complex ones and be available on-demand for consultations.

“Care is better in teams” is something that is often said, but actions speak louder. I am excited to walk the talk in my future family practice using what I’ve learned here.

Till next time,

Ali D

Today’s traditional Swedish Fika treat is a chokladboll (chocolate ball). Simply amazing!

Guest Post: Ali Damji (Canada) – Snapshots of Patient Co-Produced Care

Time really flies when you’re having fun!

This is my second reflection, from when I participated in a Study Visit with a team from Singapore Institute for Mental Health (all of us pictured above). It was co-learning at its finest, where I not learned about quality improvement and healthcare in Jonkoping, but also a great deal about Singapore too!

One of the main reasons that I traveled to Jonkoping was to learn about patients as partners, and patient-led care. This blog post will focus on a few encounters where patients co-produced better care that I witnessed firsthand.

Esther: Before I go further we have to talk about Esther. In Jonkoping, one of the key ingredients to their successes is a flipped perspective when thinking about quality improvement and change. Rather than thinking about, “What’s best for the system? Or what’s best for me, the provider?”, the question always is, “What is best for Esther?” Esther is a hypothetical patient that many of us in healthcare are familiar with. She is a person with a life beyond the walls of the institution, not purely a patient. She is elderly and frail. She has complex health needs. She lives alone. If she lacks effective primary care or transitions from the hospital back to home without support, she does not do well. She’s called a “frequent flyer”. But what about the other elements of her life? What drives her? What motivates her? And most importantly, what matters to her? And how is her problem, our problem (not long term care’s problem or the hospital’s problem – our collective problem!)? How can connections be developed and the system be built so it can respond to the things that matter most to her, beyond simply her medical needs?

While a simple concept, this is sometimes a missing step despite the best of our intentions. It is crucial to not lose sight of patients’ stated needs and preferences because they matter just as much, if not more, to overall health and wellbeing.

Amazingly, the “What is best for Esther” culture is quite visible across Jonkoping region from what I’ve seen. From the clinical microsystem level where decisions are made about how to improve direct patient care environments, all the way to the policy-making level at the government, Esther is kept in mind. For example, programs have been funded by the region because it was the right thing to do for Esther, even when it did not necessarily fall perfectly within the mandated responsibilities of the region. It could have been passed off as “not our problem, it’s someone else’s” but it wasn’t. That’s putting patients at the centre of the team.

As for the clinical examples, here are a few which struck me.

Transitions: One of the most tangible examples of thinking about what matters to patients relates to transitions in care. All patients are asked what matters to them and this turns into an individual care plan, and the system responds to those needs. Think about the last time when you or a loved one was in hospital and needed that extra bit of individualized care. What was it? Someone to look after your dog while you were in the hospital? Why can’t someone do that so you can heal and not be anxious? What about having something nice and comforting painted on the wall of your hospital room? Now don’t get me wrong, there is a place for standards and procedures, or organizations would be incredibly inefficient. But these processes must have laxity and the ability to make exceptions for the patients’ needs, and I see that balance being struck here.

One of the interventions that I’ve noticed are supported discharges where more complicated patients who live alone will have a professional visit them immediately at the time of discharge in their home and help them with the activities that are often overlooked (help with getting groceries, cooking a few meals for the patient, making sure medications are on hand, in addition to getting all the medical equipment set up). These are important factors to an individual’s health and wellness, and matter to them. The healthcare system should not only acknowledge those needs but actively work to support patients needs because that’s what keeps them healthy.

Dressed in the traditional uniform that all staff wear on the wards! In Sweden the dress requirements are strict as it has been proven to reduce the rate of hospital acquired infections. Still getting used to it! This was on my very first day on service at Eksjo Hospital!

Ward Rounds: During my clinical rotations in Gastroenterology, I always attend morning rounds. A key difference I’ve noticed here is the importance of the patient’s narrative in daily work. Unlike other wards I’ve worked at, in this particular one, the patient is invited every day to come into the room with the team when they are “running the list” (when the team looks at every patient on the ward’s most recent information about their care, reviews their case and new developments, and decides on a plan for that day). Rather than complete this process without the patient as the ward team, instead the patient is included as part of the team. The patient actually sits in the centre of the room and often drives the conversation too. This initiative was driven by the clinical leads in the department in partnership with their patients. The patients contribute their perspectives on what they feel is best for their recovery both inside and outside the hospital and the team can incorporate that into the decision making. Most importantly, it’s not a one-off encounter, but a consistent conversation that shows true partnership with patients.

Self-Dialysis: Brace yourselves, a lot to talk about here.

The self-dialysis unit in Jonkoping at the Ryhov hospital is well-known across the world. I had heard of them at The Institute for Healthcare Improvement National Forum this past December where the originators of the unit presented the story behind it to an international audience. You can read more about it here. Or check out this video!

The story behind this program is that a patient undergoing hemodialysis once asked his nurse, “Why can’t I do this myself? Could you teach me? I need control over my life” The nurse responded “How can we start?” and began teaching the patient how to perform their own dialysis under her close supervision. Soon other patients began developing an interest in doing the same thing, and eventually, the unit decided to turn it into a formal program as more and more patients became interested.

The Dialysis Unit itself has multiple streams: peritoneal dialysis, assisted (traditional) hemodialysis, and self-dialysis. Home dialysis is also available too, though many patients express their desire to keep their medical care in the hospital rather than take it home with them. These sentiments have pushed the Self-Dialysis program further and many patients enjoy being able to socialize with other patients and come for hemodialysis when they want to, giving them greater independence over their care, and their life beyond their illness. To date, approximately 60% of the hemodialysis patients are on self-dialysis with a target of 75%.

Nurses staff the unit from 7 AM to 4 PM. Patients who opt for self-dialysis begin their journey on a continuum.

The continuum used at the self-dialysis unit. Patients proceed with coaching from the nurses and patient supporters along the self-hemodialysis staircase. Health cafes provide opportunities for patients to discuss with one another and nurses in a more relaxed environment. Peer support is encouraged. Image taken of poster in unit with permission. Property of Ryhov Hospital, Region Jonkoping.

When getting started, patients typically come in during the day and are coached by patient supporters like Patrik Blomqvist, who have been through the unit themselves before. Nurses are also present to coach patients and make sure that their technique is safe and help with any issues or complications. Together in partnership with the patients, they assess their confidence and competence and coach patients towards greater independence in their dialysis. Typically it takes 4-8 weeks for a patient to feel comfortable performing dialysis from start to finish completely on their own but they decide in partnership with the team when the time is right. It is a stepwise progression. Eventually many will complete the entire process themselves, from collecting supplies from the sterile unit, interpreting labs, taking their own blood, documenting their findings, setting up their machines, administering the needles to themselves, participating in exercise while the machine starts up at the onsite gymnasium (many of the patients are awaiting transplant so maintaining fitness is important), and connecting and starting the machine and proceeding with dialysis. They then clean the unit for the next user. The machines themselves have been selected by both the patients and the nursing staff with usability for patients as a critical factor.


The team from Singapore Institute for Mental Health along with Mr. Patrik Blomqvist and yours truly! The inviting room we are situated in is the Health Cafe located in the Dialysis Unit where patients, supporters, and nurses can sit informally with one another and help one another along the journey of self-dialysis.

Unlike other self-dialysis units, this unit is open to patients 24/7. Patients who become confident and competent in their own dialysis can use their own access cards to come into the unit and dialyze themselves when it is most convenient for them, even without supervision. To do so, they must sign a paper and also must carry a cellphone so they can call for help in case of any emergency. Only 3 patients to date have had to return to assisted hemodialysis due to inability to perform self-dialysis (typically due to cognitive problems that developed such as Alzheimer’s which would have made their ongoing participation unsafe). That being said, there are patients who are in their 80s who are performing their own dialysis. Beyond the immense satisfaction of the patients, clinically, the rate of infections related to dialysis has decreased dramatically.

The story of Ryhov’s self-dialysis unit is an inspiring one. A single patient came forward and suggested a new way of doing things that better met his needs. And rather than being immediately shut down because it seemed so radical and unfathomable, the people working in the system asked, “How can we do this for you?”

And look at what was created. This is patient-centredness at its finest, where patients lead their care, and the system and those who work in it support them in that journey.

Thanks for the opportunity to see all of this (and much more!), Qulturum! It was an inspiration that I will take with me in my future career as a family doctor (happy to say I matched to this career earlier this week!)!

When I eventually interact with patients of my own back in Canada, I wish to take these lessons to heart. As a doctor, I can ask them about what their needs are, and what matters to them, not only for my care, but generally too, and then work to support and coach them as they take more ownership of their health and wellness. I will have an open mind about what is in my toolbox to help my patients, and see my patients as partners who actively participate in care, not passive recipients. This will make me a better doctor. And what’s the point of doing all of this training alongside medical school if I can’t actually use it to work collaboratively with my patients to make the macro and microsystems we live in better?

Now my blogs are a bit behind (just so much to see!), so I’ll be posting about last week’s Microsystem Festival next, followed by a post on my experiences on the wards and primary care clinics of Jonkoping region! There were also a few other site visits that happened during week 2 that I didn’t include to keep this blog more brief (e.g. Mobile Geriatrics Unit, Rehab Clinics) but I’ll place them in the other posts!

Lastly, for the foodies out here, here’s the latest delight from Fika which I have developed an addiction for: Semla! I will certainly be frequenting a certain Swedish bakery back home in Toronto to get my fix when I return.

Semla is a Swedish treat only available during certain times of the year. It is available before Easter so I’m here at a good time. The two buns are full of cardamom and made from semolina. In between is a cardamom whipped cream and beneath that is a layer of almond paste. It is simply, heavenly.
I wasn’t kidding.. I’m obsessed!

Till next time! Would love your thoughts and comments!


Guest Post: Ali Damji (Canada) Week One Reflection – Why Jonkoping?

Hello from Canada! I am thrilled to be guest posting during my study visit.

My name is Ali Damji and I am a fourth year medical student and graduate student from the University of Toronto, Canada. I am currently working towards a Masters of Sciences in System Innovation and Leadership at the Institute for Health Policy Management and Evaluation at the University of Toronto, and am hoping to enter a career in family medicine and work as a physician-leader in quality improvement and health systems in my future.

I am here at Qulturum for a 6.5 week study visit, while also participating in a quality improvement and clinical experience at Eksjo Hospital.

This is my first time in Sweden and I am very excited to learn about Jonkoping, Swedish healthcare system, and Qulturum.

So why did I come to Jonkoping, of all places?

  1. Qulturum: At my university, Jonkoping region and specifically, Qulturum, stands out for its strong reputation as an incredible influencer in the realm of quality improvement in Sweden, and worldwide. This is particularly for its emphasis on person-centred care and using the patient experience and what matters to them to drive change across the healthcare system. By focusing on what matters to patients, health outcomes and system outcomes will improve too. Even more amazingly, Qulturum has successfully fostered this culture across not just the macrosystem but microsystems too. Unlike other systems, Qulturum also walks the talk, and this culture has produced tangible results. There are several key innovations that truly deliver person-centred care such as the Mobile Geriatrics Unit that delivers specialized services at patients’ homes on demand, and the Self-Dialysis Clinic where patients work with dialysis teams to take charge of their own care, to name a few. It is not just a mantra or a directive, but an actionable cause taken up by the frontline and the government and its agencies. I look forward to seeing these innovations first hand. Being able to work with and learn from the quality improvement leaders who coach frontline staff and help cultivate these fast-paced improvements in micro and macro systems will be an immense privilege and opportunity.
Reason Number One.

2. Person-Centred Care: Since my first day at Qulturum this past week, I have been really impressed with the emphasis on looking at the entire person, and the approach to person-centred care. In the Jonkoping region, education and employment and infrastructure are seen as critical components contributing to one’s health, and are under one umbrella with health in its governance structure. The question that is always asked when making changes to the system is from the perspective of a symbolic patient, named Esther. This patient is a complex elderly patient who requires coordinated care between hospital, primary care, home care, and community care. Improvements are made to the system by looking at  “What is best for Ester? What matters to her?” The system and improvement efforts must then build around those needs. This is a flipped way of thinking from the traditional mindset, and one that I believe should be spread to all health care systems including my own back home.

Ryhov Hospital. This is the hospital where I will be participating in several sites visits next week to learn more about their Rehabilitation, Psychiatric, Self-Dialysis, Mobile Geriatrics  and inpatient units in the coming weeks.

3. Try out some QI: The QI project I will complete here will be a great opportunity to practice and develop my skills in root cause analyses, value stream mapping, process mapping, measures, defect testing, PDSA cycles, and developing a plan for a quality improvement project. I am also looking forward to working clinically in a microsystem and working with the clinical team to design an improvement, with the support of Qulturum. It will be an exciting opportunity to learn in both the marco and microsystem and understand their interconnectivity. I also look forward to sharing some of the QI work I have been involved in back in Canada and participating in co-learning.

4. Microsystem Festival and Building International Networks: Qulturum will be hosting the Clinical Microsystem Festival from March 1-3, 2017. I am looking forward to meeting QI leaders from across the world and learning from the collective expertise in the room. I also look forward to meeting other students pursuing training similar to my own so we can learn from one another.

Like many health care systems in developed countries, from my studies I have found that Canada faces several similar problems faced by Sweden: difficulty in transitioning people out of hospital into long term care and home care, controlling costs and wastage in a universal health care system while eliminating unnecessary variation, addressing the social determinants of health (Sweden has an impressive range of strategies to address issues like low income and education, leading to less spending on health, for example), challenges in moving care outside of hospitals and into the community and preventative medicine, while still providing high-quality care in all settings. and supporting patients’ needs and wishes for their care (or as in Ontario, receiving the right care at the right time, in the right place).

I believe that these are complex challenges, and we must look to the global community to tackle them. That’s really why I am here. These first 6.5 weeks are a start to that journey for me and I can’t wait to see how they unfold.

Enjoying a wonderful Swedish tradition: fika! Hot drinks and snacks fuel morning conversations and allow different departments to informally meet and discuss projects.

Thanks for hosting me here, and I can’t wait to join the team from Singapore tomorrow as we visit several sites of innovation tomorrow.

Until next time!