Whole System Transformation

(1)

©Göran Henriks, Mats Bojestig Sven-Olof Karlsson, Jönköping

www.lj.se/qulturum

Whole System Transformation

Intentional Design

Sven-Olof Karlsson, CEO

Göran Henriks and Mats Bojestig

Jönköping Healthcare Services

Sweden

©Göran Henriks, Mats Bojestig

Who are we?

Bridging the Gaps

Sven-Olof Karlsson

(2)

www.lj.se/qulturum

In this interactive session…

• You will be presented

key ideas and concepts

for

moving whole system transformation beyond the

”experimentation” phase to intentional design, including

– the core principles

– conceptual framework

– leadership support needed

• We will also describe

– How to establish mission values

– Creating the necessary processes and structural design

elements

– How to develop the best possible clinical results

www.lj.se/qulturum

After this presentation you will be

able to:

• Present a framework and key concepts in system

thinking for leading innovation work

• Recognize what is needed from management

perspective to develop the capacity to transform your

system

• Initiate a framework for spread of new ideas in your

system

(3)

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Sweden

Jönköping county

Europe

Jönköping

County Council is responsible for

the public health care services

Jönköping

Höglandet

Värnamo

160 new patients staying over night at the hospitals/day

9 newborns/day

3 Hospitals

34 Primary care centers

9,500 employees

350,000 inhabitants

6.100 visits per day

1.500 visit a specialist/day

1.300 visit to g.p./day

(300 visits to private

doctors/day)

(4)

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Jönköping County

Beside health prevention,

health and medical care

the County Council is

responsible for:

•

Dental care

- 35 clinics for general dentistry

- 10 for specialist dentistry

•

Education and research

•

Culture & education

•

Regional support & activities

- County Theatre and Music

- Public transportation

- Regional development

11 municipalities

Jönköping

Höglandet

Värnamo

Eksjö

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• Health Care in Sweden is financed through

taxes

• The County Council Assembly

– 81 elected politicians

– Elected every fourth year

– Public meetings four times a year

– The politicians are deciding the work of the County Council

at a general level and the tax rate

(5)

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Evaluation grid: Integrating Improvement into business

(Source: API)

Just beginning Aware Informed Integrating Understanding Successful and renewing

Score your org./unit: Area Score = 0 Score = 2 Score = 4 Score = 6 Score = 8 Score = 10

1 Purpose No written statements Statements exists Mission and tenets defined and visible

Communicated and understood by employees

Used in align and guide the business

Fully integrated into the structure 2 System Work as a process is

not understood

Major processes and products have been documented

Relationships between processes are documented

System thinking and language is common

Systems diagrams are used in business

Management systems have integrated the system view 3 Family of meas-ures Financial data is viewed periodically

Financial and other operational measures are used Family of measures is assembled Balanced set of measures reported graphically Set of measures aligned and variation understood

Measures are integrated into management systems 4 Informa-tion Information is gathered on ad hoc, reactive basis System is based on passive information System is well documented and includes active sources Information is documented and communicated Comprehensive system with analysis and synthesis for decision making

Marketing leads and integrates information system 5 Planning for improve ment No formal planning, reactive culture Planning for improvement is done on an informal basis A formal documented process exists for planning improvement

Integrated process identifies objectives, efforts, and resources

All other planning processes are defined and linked

Planning system is improved and integrated in all areas 6 Mana-ging improve ment efforts No system exists to manage improvements Improvements recognized on an as-needed basis and resources assigned

Leaders provide formal guidance for individuals and teams

Improvements are guided by planning; leaders are learning

The impact of improvement is understood and managed Improvement system is integrated in business and regularly improved 7 Model for improve ment No standard approach to improvement efforts Various approaches are used for improvement

Training on the Model for Improvement and expectation of its use

Theory behind the Model for Improvement is understood Improvements are managed as PDSA cycles

The Model is routinely used by all 8 Manage

ment system

Structure does not exist to make improvement a focus

The need for improvement is recognized and responsibility assigned

A formal system for improvement is defined Top management assumes responsibility for integrating improvement Improvement is linked to planning and other key business activities

Improvement is completely integrated into all aspects of operating & developing the business

Our

inhabitants

should get

care when

they need it

Improvements based

on knowledge

(6)

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(7)

Summa index

Di

ff

i

K

r

175

150

125

100

75

50

2000

1500

1000

500

0

-500

-1000

0

Scatterplot of Diff i Kr vs Summa index

Summa index

D

iff i

K

r

175

150

125

100

75

50

2000

1500

1000

500

0

-500

-1000

0

Västerbotten Norrbotten Västra Götaland Halland Skåne Östergötland Gotland Jönköping Kronoberg Blekinge Gävleborg Västernorrland Dalarna Kalmar Jämtland Värmland Örebro Västmanland Uppsala Sörmland Stockholm

(8)

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Comparison between counties in Sweden

The lower the rate is the better score

0 50 100 150 200 250 Stoc khol m Sö rmla nd Upps ala Västm anl and Örebr o Vär mlan d Jäm tland Kal mar Dala rna Vnor rland Gä vlebo rg Blek ing e Krono berg Jön köp ing Go tland Öste rgö tland Skån e Halla nd Väst ra G. Norr bot ten Vbott en Serie1

…...Change the outcome

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Comparison between counties in Sweden

- Lower points is better ranking

Total

score

(9)

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Results, annual report 2005 and

prognosis for 2006

Per cent shares of net costs

Average for

Sweden

Jönköping

Increasing self-government

gives us new questions

• The demand for

competence

increases in the daily work

• Organizations are becoming dependent of that the staff

really does

understand

their working tasks

• The leaders possibilities to develop the work and

business is totally dependent of the employees

possibilities to

develop their understanding

People act from their

understanding of reality

(10)

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Some problematic assumptions

1. Customer relationship

– focus on the individual

treat, access, equity

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2. Problems with the performance

Headline: Patients with cancer

have to wait in line

(11)

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3. 100% –

2005

2015

100 %

1%

Current activities

Continuous

improvements

New

activities

”Special”

competence

Medication

New technology

4. New employees –

”Social movement”

Patient safety

New working hours

Center – periphery

(12)

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Improvements are

being done

as projects

Infrastructure to

lead/manage and

improve

A new level is

created daily with

improvements and

a new design

1

2

3

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Design

-development

Improve – project

Management

-infrastructure

I

II

III

(13)

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How to integrate improvements in your

organization

Integrating Improvement into business – evaluation grid for Jönköping

(14)

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100% participation in

breakthrough activities

Identify/prioritize possibilities:

-What does the patient/customer say?

-What does the process say?

Rapid improvement cycles

Widespread training

Learn new habits and ways of working

Project to project, process to process

Development within units

I

II

III

Design

-development

Improve – project

Management

-infrastructure

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Basic strategies for improvement work

Increased access is reached by:

The activity has

a balance

between capacity

and demand

No waiting list

1

2

Increase

the capacity

Reduce the

demand

Manage

variations

Work to get rid of

the rucksack

(15)

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• Start a reception for district nurses where patients

can book a visit

• Make it possible for

physio-therapists to do first exams

• Start infection receptions with

reg nurses

• Schedule planning – to balance

capacity to demand

• Telephone routines

- more time for telephone calls, more staffing

- standardize and document advice giving

Most Common Changes

Access

Ref:Strindhall

Jönköping 1999

Gotland 2000

Kalmar 2000

Västra Götaland

2000

Skåne 2001

Stockholm 2002

Uppsala 2001

Östergötland 2001

Värmland 2001

Västmanland 2001

Västerås 2003

Halland 2004

Gävleborg 2005

Norrbotten 2006

Kronoberg 2000

Blekinge 2002

Collaboratives on Access

called “Bra mottagning”

Spread in Sweden 1999 – 2006

Participating teams: more then 300

Participants: more then 2000

(16)

www.lj.se/qulturum 2,5 months 6 months 12 months Max 3 days 3 days 1 month Min 14 days 1 week 3 months Median 2,5 months No progress 3 months Hospital clinic 5 3 days 1 month 1 month Primary care centre 6

6 days 13 days

1 month Primary care centre 5

3 days 6 days

1,5 months Primary care centre 4

2 weeks 6 months 12 months Hospital clinic 4 2 months 0 6 months Logopedic unit/ hospital clinic 3 10 days 3 days 3 months Physio therapy at

primary care centre 3

17 days 13 days 3,5 months Hospital clinic 2 14 days 1-3 days 1,5 months Primary care centre 2

1-3 days 1-3 days

4 months Primary care centre 1

3 weeks 1 week 2 months Hospital clinic 1 Result 2006 Result after participating in BM 1-3 (1999-2000) Waiting time before

start of BM1-3 (1999 – 2000) Units in Jönköping County Council

Collaboratives

about Access

“Bra mottagning”

Results from participating

units in collaborative 1 – 3;

Result before, after and

six years later 2006.

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QUICC

Important improvements

to national guidlines

- the result of the Swedish improvement work called

“Quality Improvement in Cardiac Care” (QUICC) project

Bertil Lindahl, Gunilla Lindström, Anette Peterson*, Christina Åberg,

Mats Bojestig* and the QUICC study group, Uppsala Clinical Research

Center and Dept of Cardiology, Uppsala, and *Dept of Internal Medicine,

Eksjö, Sweden.

Economic support from Federation of Swedish County Councils

Ref Quality Management in Health care Jan 2007, AM Heart J. 2006:152:1175-1181.

(17)

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0

5

10

15

20

25

30

35

40

45

ACE-inh

C Q

Lipid low

C Q

Clopido.

C Q

L.m.w. hep

C Q

Corai

C Q

p=0.001

p=0.36

p=0.008

p=0.01

p=0.028

Exact increase of how they follow (%)

Number of hospitals that reach 70 %

following in 4/5 and 5/5 treatments

Number of hospitals that reach 70 %

following in 4/5 and 5/5 treatments

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

Control

QUICC

0

4/5

5/5

(18)

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antal sjukhus bredvid cirkeln och referenslinje längs oförändrat index.

Figur 29d. Sjukhusens kvalitetsindex 2005 jämfört med 2003 (minst 10 patienter i målgruppen), med

K

va

lit

et

si

nd

ex

2005

0 1 2 3 4 5 6 7 8 9

Kvalitetsindex 2003

0 1 2 3 4 5 6 0 1 2 3 4 5 6 7 8 9 6 5 2 1 5 6 4 5 4 1 1 1 1 2 2 3 3 2 1 1 1 1 1 2 1 1 2 2 1 1 1

Quality index 2005 comp. to 2003

QUICC-hospital

Red line = reference line for no change in index

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Promising ideas and concepts

• “Senior alert”

• “Your care

”

• “Care pre

vention”

(19)

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The Care Prevention Project

¾

Four teams created four care programs; for Prevent

falling, Nutrition, Ulcers and Pain (2004/2005)

¾

Create a better process for the preventive work in the

whole county and better cooperation

¾

Create a way of working for all elderly people, for

everybody in the county and for the whole care chain

Target group for Care prevention:

Patients age 70 or elder!

Patients

with need of

treatment and care

Inpatients at the

hospitals having risk

getting ulcers, falling

and malnutrition

Special risk groups

Prevention work for

population/

Individuals

before getting ill.

Help them live

healthier

(20)

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The Care prevention process

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(21)

Number of Risk patients where something was done

(22)

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Number of patients where something was done

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A new

national

register:

Med.

treatment

and care for

elderly people

(23)

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Now

Patient

enrolled

Pr. ulcer

develops?

Treatment

of pr. ulcer

Patient

dicharged

Yes

No

Value Assessment

53 000 episods of

care/year

At 8 % of

episodes

pressure ulcer

develops

Treatment of

pressure ulcers

costs 7.6

million dollars

New

Pat

enrolled

Pr. Ulcer

develops?

Treatment

of pr. ulcer

Patient

discharged

Yes

No

Value

assessment

53 000

episodes of

care/year

Assume that

half of the

pressure ulcers

can be

prevented

4 million

dollars

Risk?

Preventive

treatment

Assessment

acc. to

Norton

Yes

No

ALL patients

are

assessed

572 000

dollars

8 % of

patients has

a risk acc.

to

assess-ment

572 000

dollars

Total cost

7.6

million

dollars

Total

cost

5

million

dollars

Business Case:

Pressure Ulcer

100% participation in

Rapid improvement cycles

Widespread training

I

II

III

Design

-development

Improve – project

Management

-infrastructure

Build needed infrastructure

Identify key processes

Measure and follow outcome.

Learn how to assess

Quality control

How we organize

Early warning signals

Prioritize what to do

System understanding/How we do

The Diamond Picture

(24)

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•

safe

•

knowledge based

and efficient

•

patient focused

•

effective

•

equal

•

timely

There is a lot of exciting things going on

and think when we can promise…

…a Health Care that is

Good Health Care

Swedish Board of

Healthcare and welfare

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What is leadership?

“A group of people going in the same direction

by the will and the conviction of their own”

(25)

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Breakthrough

of what is good

Clinical

improve-ments

Safety

Medication

etc

Good exemples

Enthusiasm

Coop.

Good access

Breakthrough

Logistics

From indoor to outdoor

From physician to

other category

From readmission

to new visit

etc

Now

Future

Organiza-tional

changes

Swe

:“Capitering”

1 physician per

1500 inhab

“Cue-money”

etc

Economic

requirements

How?

What?

The New leadership

What does it take?

… a dialogue that...

• creates participation

• letting people grow

• allows many to become

winners

To get a group of people, go in the same

direction by the will and the conviction of their

own, you have to have...

(26)

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A good leader

is recognized by

• a strong will

• courage

• persistence

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A good leader

is recognized by

• a strong will

- to have this, you need

knowledge and a

conviction

of your own

• courage

(27)

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is recognized by

• a strong will

- to have this, you need

knowledge and a

conviction

of your own

• courage

- requires that you don’t hesitate

or bend when you meet resistance

• persistence

A good leader

is recognized by

• a strong will

- to have this, you need

knowledge and a

conviction

of your own

• courage

- requires that you don’t hesitate

or bend when you meet resistance

• persistence

- means that you for long time

stick to your strategy

(28)

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A learning organization

…has to have a learning leadership.

Jönköping’s group of leaders have spent more

than 1.000 hours/year since 1998 on Quality work!

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Six challenges for leaders:

The Basic Values

1.

The development of more

profound knowledge and

capacity in improvement work

2.

Cooperation over unit-,

preserve- and competition

boarders

3.

The leadership of system

results rather than project

results

5.

The maintenance of purpose

and organization/ business idea

6.

4.

The creating of a work (a business) that generates

reliability, good economizing and value for the

inhabitants

(29)

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The important of

relations

Vision and goal:

Best possible life

- the whole life!

Develop

Value

Budget plan and

Plan for 2008 – 2009:

The Region

Cooperation routines and

resources

Health care

• Support self care

• Offer different kind of health care

• Deliver diagnostics, caring and rehab

• IT-support

Well informed

active inhabitants/

patients

Well trained and

prepared care

teams

Best possible

value

and clinical

results

(30)

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Balanced scorecard

QUALITY AS A BUSINESS STRATEGY

0% 20% 40% 60% 80% 100% Economy Process/productivity Customer/patient Learning/Renewal

Overall strategic aims of

Jönköping County Council:

With Good financing we mean activities that create values leading to satisfied customer/-patients with high quality of life.

This requires that health care... • has access.

• is based on a overall view regarding patient flow and processes. • reaches/performs the best clinical • results with the best safety. • is performed to lowest possible costs. To live up to this demand it is of necessity to have motivated and participated employees.

Activities, Breakthrough series etc

Improvement collaboratives, 2007

Work in a smarter way!

(31)

Value compass

Strategic areas that we

are working with in

Jönköping

Legislation from the

Swedish National Board

of Health with IOM aims

and Deming methods!

Strategic aims for the

County council of

Jönköping

Overall Strategic Aims of Jönköping County

Council/Health care services:

With Good financing we mean activities that create values

leading to satisfied customer/-patients with high quality of

life.

This requires that health care...

• has access.

• is based on a overall view regarding

patient flow and processes.

• reaches/performs the best clinical

• results with the best safety.

• is performed to lowest possible costs.

To live up to this demand it is of necessity to have

motivated and participated employees.

(32)

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Costs per

discharge

Access

Patient

with

Health Need

Process of

Providing Services

Patient with

Health Need

Met

3rd Available

Appointment

SF-6

TM

HSMR

Mortality

ADE

Satisfaction

Clinical

Outcomes

Functional

Outcomes

Costs

Inpatient

Satisfaction

Costs

per

capita

Mortality

Staff turnover

System measures for Jönköping County Council/Health care services

Reports

to PSR

Actual year

worker

Sick leave

End of life

Numbers

dying in

Hospital

Re-imbursement

within 30days

Number of care days

during the last 6

months of life

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Tillgänglighet och bemötande

Prevention/Egenvård Kliniskt förbättringsarbete

Customer

Citizens

Process/

Production

Learning &

Innovation

Economy

Success factors

Development areas

Access / How we treat patients

Prevention / Self-care

Cooperation

Clinical result improvements

System m

easures

Deve

lopin

(33)

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HSMR Reducerat, sjukhusvårdtillfällen samt endast verifierade överföringar

0,50 0,60 0,70 0,80 0,90 1,00 1,10 1,20 1,30 1,40 1,50 Stockh olm Dalarn a Krono berg Västerb otten Jämtlan d Västra G ötalan d Hallan d Jönk öping Östergöt land Västern orrlan d Skån e Gotlan d Norrbotten Kal mar Värm land Gävle borg Blek inge Upps ala Örebr o Söde rman land Västm anlan d

HMSR, hospitals per county in Sweden

(34)

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IT

Envir

.

Adm.

V a l u e f o r p a t i e n t i n c r e a s e s

Access

How we

receive

Coopera-tion/flow

Clinical

improvement

work

Patient

safety

Medication

Learning

and

innova-tion

Good

finances

Reliability

Strategic

Improvement areas

Prevention

Self-care

Leadership

Transformation

in depth and

width

350 team

21 team

Big Group Healthcare

60 team

+ 43 team i National Quality Registers

80 team

60 team

More than 550 teams and

4,000 employees have

participated in programs

2002-2007.

30 team

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Open comparisons

•

Perspectives

A. Med. Results (35)

- Clinical results

- Evidence based care

- Safe care

- Cooperation

- Prevention

B. Patient experiences (9)

- Patients view of the HC

- Populations view of HC

•

C. Assess (4)

- Waiting times

- Telephone access

•

D. Costs and productivity (9)

- Costs per inhabitant

- Productivity

(35)

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Competence Center for Swedish National

Registers on Heart Failure

From one of the largest daily

newspapers in Sweden:

Best intensive care units

Hospitals

Worst intensive care units

Hospitals

Best hospitals in

Stockholm

(36)

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QI work

Patient

results

Expectations towards QI

Quality Management in Health Care submission, Improvements for patients? Findings from an

independent case study of the Jönköping improvement program

John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm,

and Professor of Health Management, Faculty of Medicine, Bergen University, Norway. Anthony Staines

MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France – Vice-Chairman of sanaCERT,

Accreditation Body for the Swiss Hospitals.

www.lj.se/qulturum

Patient

results

QI work

Literature review. No evidence of patient results through QI

Quality Management in Health Care submission. Improvements for patients? Findings from an

John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and

Professor of Health Management, Faculty of Medicine, Bergen University, Norway.

Anthony Staines MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France – Vice-Chairman of

sanaCERT, Accreditation Body for the Swiss Hospitals.

(37)

www.lj.se/qulturum

Patient

results

QI work

Jönköping

Situation of Jönköping County Council

Quality Management in Health Care submission. Improvements for patients? Findings from an

John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm,

and Professor of Health Management, Faculty of Medicine, Bergen University, Norway.

Anthony Staines MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France – Vice-Chairman of

sanaCERT, Accreditation Body for the Swiss Hospitals.

Patient

results

QI work

t

Hypothesis suggested by this case.

A threshold (t) in QI work (zone of noise below which results will not show)

Quality Management in Health Care submission. Improvements for patients? Findings from an independent case

study of the Jönköping improvement program

John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and Professor of

Health Management, Faculty of Medicine, Bergen University, Norway.

(38)

www.lj.se/qulturum

What does it take to become a leader?

– How to establish mission values

– Creating the necessary processes and structural

design elements

– How to develop the best possible clinical results

www.lj.se/qulturum

100% participation in

Rapid improvement cycles

Widespread training

I

II

III

Design –

development

Improve – project

Management

-infrastructure

Build needed infrastructure

Identify key processes

Measure and follow outcome. Learn

how to assess

Quality control

How we organize

Early warning signals

Prioritize what to do

System understanding/How we do

The Diamond Picture

Strategic compasses

New arenas: Big Group HC

• Lean Design

• Value chain analysis

(Toyota Prod. System)

• Micro system

• Everyone is creating

from their position

• Drive both outcome and

responsibility for resources

• Working without borders

• From chain to unbounded

(39)

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Interviews in Jönköping Nov 2007

John Black, Lean consultant and Gary Larson, Parc Nicolett

Healthcare system vision 2010

Ea

sy

to

u

se

Sta

ff p

art

icip

atio

n

Everyone works to

optimize processes

in the system

Health care

system

(40)

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Level of ambition

Strength in

cooperation

Successful project

Good enough

Strategic

improvements

Transformation

The Challenge!

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Cooperation over

boundaries

Permission to

test new things

Conflicts

Status quo

Small changes

in current design

Renewed roles and

tasks

How to support the force of

development

(41)

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Challenges:

To become as good as you can

•

The big steps in science have not always

been the result of a specific discovery

they have emerged from changing

reference frameworks and looking at

things in another light/from another

perspective.

Edward de Bono

The oldest symbol for ”mind” in the Chinese

written language is an outline of a heart

– to view things with a heart is maybe

more than a metaphor, it is

”extension of awareness that

characterizes

seeing from the whole”

Peter Senge

(42)

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web:

http://chain.ulcc.ac.uk/chain/index.html

e-mail:

[email protected]

Nod for Scandinavia:

Qulturum,

[email protected]

“CHAIN provides an opportunity

to find out what is happening

within health & social care

regionally and nationally, a source

of e-networking, exchange if ideas,

and not having to re-invent the

wheel”

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Learning focus

yesterday

Learning focus

we need more of

The thing that

counts...

Knowledge

through……

The

knowledge...

We manage

through...

We look for the

knowledge...

It is all

about...

For this

we

need

other

form of

support

What?

At the libary

On Google

We act into

the new

We teach and do

together

Seminars,

lectures

Goal!

My

perfor-mance

Saved in

stores until

asked for

Spread directly

everywhere

Result!

My

development

The Customer’s

development

(43)

www.lj.se/qulturum

For this

we

need

other

form of

support

What?

Good websites

Intranet and extranet for competence development

Video conferences

Web access

Telephone conferences

Measures

Presentation techniques

Simple ”papers”

Peter Senge

• ”The tools and ideas in this book (

The 5th discipline

)

are to destroy the illusion that the world is created

of free-standing focuses without relations in between.

• When we abandon this illusion – we can built

”Learning organizations”

–

organizations where…

- people continuously increase their ability to

accomplish the results they really pursue,

- new and expansive mind patterns are nourished,

- common ambitions at let loose and

- people continuously learn how they can learn together”

(44)

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How can we learn from other high

performing systems?

www.lj.se/qulturum

Service

Excellence

(45)

www.lj.se/qulturum

Putting the customer first

SCANIA (GREAT BRITAIN) LIMITED

“Everything Speaks”

(46)

www.lj.se/qulturum

Everything Speaks

www.lj.se/qulturum

Everything Speaks

(47)

www.lj.se/qulturum

SCANIA (GREAT BRITAIN) LIMITED

Customer Service

Training and Education

(48)

www.lj.se/qulturum

Scania Production System

(Scania Performance System)

www.lj.se/qulturum

SPS Whiteboard

•Local Teams

•Whiteboard – for issues

•Everything speaks

•Measurement

•Local remedies

•Intranet system to raise profile

•Intranet system of good practice

(49)

www.lj.se/qulturum

Scania Performance System

•Measure

•Find the obstacle

•Remove the obstacle

•Measure again

•Move on

•Keep it simple

Staff Recognition

•Launched at the conference

•Supported with posters

•Internal & external nominations

•30 plus nominations per month

•All acknowledged

•Good news published

(50)

www.lj.se/qulturum

Communication

www.lj.se/qulturum

Patient safety

= Eng: Many scarcities

Excerpt from a patient register

discussed in Swedish court.

(51)

www.lj.se/qulturum

R

is

k

an

d

S

af

et

y

w

he

el

R

is

k

an

d

A

ct

io

n

an

al

ys

is

M

an

ag

em

en

t f

or

ce

fo

r p

at

ie

nt

s

af

et

y

Im

pr

ov

em

en

ts

in

m

ed

ic

ia

tio

n

HSMR

Mortality

AE - Glober T

rigger Tool

ADE (medica

tion incidents)

Reinbursments

Infections

”Senior Alert”

– nat. register

Cost per capita

• Develop MIG-t

eam

• Evidence base

d care in heart f

ailure

• Plan and do m

edication tuning

s

•Prevent centra

l line infections

• Preventwound

infections after

operation

• Prevent ventila

torassociated

pneumonia

• Prevent harm

s with potential

dangerous drugs

• Prevent surgic

al complications

- introduce ”SC

IP”

(Surgical Care Im

provem. Project)

• Prevent ulcers

• Prevent MRSA

infections

• Evidens based

care for patients

with

heart failure

• Engage board

• Prevent unary

tract infections

• Prevent falls

Areas

Measures

Meetings

and methods

A

cc

es

s

+B

al

an

ce

C

ou

nt

er

N

at

io

nl

a

re

gi

st

er

s

M

ea

su

re

s

fo

r l

ea

di

ng

Le

ad

er

sh

ip

pr

og

ra

m

s

IT

-s

up

po

rt

P

at

ie

nt

’s

di

re

ct

ch

an

ne

l

Safe health care – every time!

1. Develop

MIG-teams

2. Improved

care for pat

with congestive

heart failure

4. Prevent

central line

infections

5. Prevent

surgical

site infections

6. Prevent

ventilator

associated

pneumonia

7. Prevent

harm from

high-alert

medications

9. Prevent

pressure

ulcers

10. Reduce

methicillin

resistant

infections

8. Reduce

surgical

complications

11. Improved

care for acute

myocardial

infarction

12.Governance

leadership

“Boards

on board”

14. Prevent

harms caused

by falls

13. Prevent

unary tract

infections

Patient safety activities

14 areas

3. Prevent

adverse

drug events

(52)

www.lj.se/qulturum

In Jönköping 14 interventions

12 interventions same as the 5 million Lives Campaign in US:

1. Deploy Rapid Response Teams…at the first sign of patient decline

2. Deliver Reliable, Evidence-Based Care for Acute Myocardial

Infarction…to prevent deaths from heart attack

3. Prevent Adverse Drug Events (ADEs)…by implementing medication

reconciliation

4. Prevent Central Line Infections…by implementing a series of

interdependent, scientifically grounded steps

5. Prevent Surgical Site Infections…by reliably delivering the correct

perioperative antibiotics at the proper time

6. Prevent Ventilator-Associated Pneumonia…by implementing a series

of interdependent, scientifically grounded steps

7. Prevent Harm from High-Alert Medications... starting with a focus on

anticoagulants, sedatives, narcotics, and insulin

www.lj.se/qulturum

8. Reduce Surgical Complications... by reliably implementing all of the

changes in care recommended by SCIP, the Surgical Care Improvement

Project

9. Prevent Pressure Ulcers... by reliably using science-based guidelines for

their prevention

10.Reduce Methicillin-Resistant Staphylococcus aureus (MRSA)

infection…by reliably implementing scientifically proven infection control

practices

11.Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to

avoid readmissions

12.Get Boards on Board … by defining and spreading the best-known

leveraged processes for hospital Boards of Directors, so that they can

become far more effective in accelerating org progress toward safe care

Two more in Jönköping:

13. Prevent urinary infections

14. Prevent falls connected with caring

(53)

www.lj.se/qulturum

Period: 2004 – 2006

•

In Jönköping we have been working with reducing

mortality

•

Getting the question on the agenda in Swedish

healthcare and clarifying what this is all about

Mortality

Results:

•

Appr 130 lives saved

•

Rapid response teams have been created

•

ADE

•

Clinical infections reduced:

•

The Orthopedic departments at two of our hospital has

become among the best in Sweden

HSMR/ Mortality

Inpatients

satisfaction

SF6

Cost per capita

Primary

Secondary

Palliative mortality

ADE

LÖF

Reimbursements

within 30 days

Average number of care

days the last 6 months

3rd Available

Time

Hospital costs per patient

Sick leave

POMS

Actual yearly

workers

Jönköping

System measures

(54)

www.lj.se/qulturum

A1. Health political

indicator

Cancer A11-13

D3

D4

D5

A2. Medical

political

indicator

B2,3. Faith in

health care

D1. Costs per

inhabit. (D2, D6)

Costs per performance

(D7-9)

Cost effective choice of

treatment (D7-9)

Population B1

Patients B4-8

Stroke patients B9-10

Access C1-4

Heart surgery available A36

Orthopedic available A44

Cancer A14-15

Delivery/Mother care

centers A17-18

Delivery/Mother care

centers A16, 19-20

Stroke A25-26

Stroke A27-30

Diabetes A21-24

Heart A31-32

Heart A33-35, 37

Could have been

avoided SV A3

Orthopedics A38-39, 41

Other treatment A46-48

Medication A7-10

MRSA A6

Influenza A5

Other treatment A45

Orthopedics A40,42-43

Primary

Secondary

Open Comparisons

Peter Kammerlind

www.lj.se/qulturum

The Platform and Model for Development

Understanding system

Know-ledge

Change

psychology

Understand

variation

Methods and Tools

1.

Description of Processes and System

2.

Using measures

3.

Organize ones Data

4.

Describe Variation

5.

Describe Links and cooperation

Act

Plan

Study

Do

What do we want to accomplish?

How do we know that

a change is an improvement?

What changes can we do

that lead to improvements?

The Model for Improvement

(55)

www.lj.se/qulturum

Why we do this and…

We want to do it in different places and in different ways

from what is most suitable for the context there is

The Microsystems makes us…

- have “care joy”,

- have better goal fulfillment,

- chase waste that don´t add value

- use good development methods

where we measure every day

“Everyone has the right to stop

the production line”…

• Built storyboards

• Do the right thing rom the start

• Link to other micro systems

(56)

www.lj.se/qulturum

Changes for those we are

here for gives us a more

joyful job and good finances!

ROADMAP for teams that want to develop knowledge

about the micro system in their daily life

We start from the

patients/customers need

1.

Best for the customer

2.

How we recieve

3.

Access

To go from our world to the customer’s perspective

1. It is the total result that counts

2. Reliable ways of working gives the best possible result

every time

3. Demand managed ways of working – a condition for tact or beat

4. The right thing for me: Get hold of the problem, do something

about all that is wrong, notice returning problems, unusual things

that go wrong and quality mistakes.

Give quick feedback to get increased quality.

Continuous improvement

– to work in a smarter way

Micro system – multiprofessional

teams with focus on the ones we

are here for

Learn to discover

waste

Examples of waste:

• Do more than what is

creating value

• Lengthy procedures

• Unnecessary movements of

patients and staff

• Visits and meetings that do

not have necessary things in

order

• Waiting times

• Meeting with wrong

participants

• Action plans and activities

based on normal variation or

upon occational events

Ref: Bojestig, Edvinsson, Nilsson, Henriks

www.lj.se/qulturum

Mesosystem

Microsystem

Macrosystem

System levels

Ref:Quality by Design

Bojestig,Henriks

(57)

www.lj.se/qulturum

Eugene Nelson

Paul B. Batalden

Marjorie Godfrey

How to redesign health services

processes to improve quality, add

value, reduce variation, and improve

morale, in such a way that frontline

caregivers lead the process of change,

rather than obey it.