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The Sweden Story

An Interview with Dr. Marcelo Rivano Fischer

By Jing Walker, International Advisor, CARF Europe

Skåne University Hospital
Department of Neurology and Rehabilitation Medicine in Hoor, Sweden.

In 1996, Lund University Hospital in Sweden became the first organization outside North America with a CARF-accredited program. Since then, the organization has restructured into Skåne University Hospital, where four accredited programs and two clinics now provide rehabilitation services. The organization is preparing for its seventh accreditation survey in early summer of 2018.

Individuals with neurological injuries and diseases are the primary populations served by the hospital’s medical rehabilitation unit. It runs inpatient programs for spinal cord injury and brain injury and a comprehensive inpatient rehabilitation program for persons affected by stroke. In addition, the pain rehabilitation unit offers programs to those with chronic non-cancer related pain.

Already one of the largest rehabilitation medicine clinics in Scandinavia, why is Skåne University committed to pursuing CARF accreditation?

Dr. Rivano speaks with CARF
During a recent interview, department head Dr. Marcelo Rivano Fischer discussed the organization’s journey with CARF, which began with the first MED 101 training he attended in 1995.

At that time, Dr. Rivano and his hospital were looking for a system of quality oversight that supported what the organization valued: measuring outcomes, quality-driven services, and a focus on persons served. Lund saw rehabilitation as highly personal and believed a person-centred philosophy should be part of any rehabilitation program’s DNA. The organization’s leadership felt CARF was a good fit, particularly because it was the only accreditor at the time that embraced this philosophy. Instead of focusing heavily on laboratory facilities and fancy equipment, Dr. Rivano’s team found CARF’s process had them asking themselves what is best for the persons served.

Like many programs find when initially preparing for CARF accreditation, the beginning was not easy. A top-down strategy with substantial support from leadership was needed at the introductory phase to drive adoption and conformance. But the secret to a long-term commitment lies in universal buy-in, Dr. Rivano says. “For any quality system to be successful, it takes not only leadership support, but also the in-depth understanding of frontline therapy.”

The mindset at the hospital shifted over the next nine years. Changes to everyday practices began to happen for reasons deeper than ‘because CARF says so,’ Dr. Rivano says. Instead, personnel were motivated increasingly by a desire for quality improvement while using CARF standards as a guide.

Between 2002 and 2010, Dr. Rivano and his team introduced other European and Swedish rehabilitation centres to the CARF process. “We need a common language to facilitate a quality culture in the healthcare industry,” Dr. Rivano explains. Currently, Sweden has 20 CARF-accredited providers covering a variety of programs ranging from single-discipline outpatient medical rehabilitation to home and community services.

“It has been inspiring to exchange ideas and share consultation,” says Dr. Rivano, who is also the first European CARF surveyor and has surveyed around the world. “There is always something we can learn from each other. CARF is not mandatory in most countries. People choose CARF because they believe in quality. It means after going through the process, what’s left won’t be just piles of documentation but the values shared among us.”

Challenges looking forward
Dr. Rivano also shared some insights into challenges the industry faces worldwide. He identified three challenges:

  1. Rehabilitation outcomes are influenced by multi-cultural and diversity-based factors. Globalization clearly has posed a challenge in interpreting and satisfying the needs of persons served.
  2. Healthcare strategies have tended to favour youth and working-age adults, whereas the number of active older adults has increased in recent decades. Rehabilitation services have to adapt to demographic shifts.
  3. Healthcare expenses remain a common, major issue globally. In order to survive, service providers must allocate limited resources toward strategies that produce the best possible outcomes. They need to address socioeconomic factors and justify services based on data and evidence. For instance, Dr. Rivano and his team are collaborating with Swedish National Insurance Agency to study the effectiveness of pain rehabilitation therapies. They periodically track the number of sick-leave days taken after patients are discharged from the rehab programs.

Although access to advanced equipment and technology is important, the current and growing emphasis is on helping people re-enter the lives they desire. More and more policymakers are recognizing that outcomes are key. Demand for CARF accreditation is growing internationally, and we expect industry dialogue will continue to evolve around improving outcomes as we collectively adapt to a variety of global challenges.

Editor's Note: This article first appeared in the December 2017 issue of CARF's Medical Rehab Connection newsletter (2017, Issue 4). View the December issue, or subscribe to receive future issues, at:

(Medical Rehabilitation)

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Thank you, Sandra. It takes a special kind of devotion and willingness to be the first through the door on a quality initiative. We're proud to continue to partner with Skåne University Hospital both in its own quality efforts, as well as others' in Europe.

Posted by: Brad Contento (CARF) at 3/8/2018 3:20:36 PM

This really demonstrates how visionary Skåne University Hospital and the leadership was and still is. Wonderful sharing of this history. Truly patient-centered. Thank you.

Posted by: Sandra Chin Sang at 3/8/2018 3:05:18 PM

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