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Centre for Healthcare Improvement (CHI)

Chalmers and Healthcare in Collaboration

For Sustainable Healthcare

CENTRE FORHEALTHCARE IMPROVEMENT

Andreas Hellström, Assistant Professor Svante Lifvergren, M.D. Co-Director, Centre for Healthcare Improvement Co-Director, Centre for Healthcare Improvementandreas.hellstrom@chalmers.se svante.lifvergren@chalmers.se

www.chi.chalmers.se

Centre for Healthcare

Improvement (CHI)• a research and education centre at the Department of Technology and

Economics, Chalmers University of Technology

• organizes cooperation between researchers from different discipline and led by two directors.

• conducts research and education in improvement, innovation and transformation of health care.

• our goal is to collaborate with Swedish Healthcare to create, translate and disseminate research-based and action-oriented knowledge.

• to achieve this goal, CHI focuses on two parts - research and education.

ApproachesOrganizing and managing

• Principles for organizing, organizational learning, how to deliver value, organizational change…

Data-driven operational development• Applied statistics, ”from data to improvement”,

visualization…

Processes and flow• Value focus, capacity planning, coordination,

integration…

Improvement knowledge• Variation, systems understanding, psychology…

Sustainability• Social, financial, environmental…

Action oriented • Action research – interactive research

• Experiential learning

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CENTRE FORHEALTHCARE IMPROVEMENT

Management research

Healthcare practice

Learning about healthcare developmentLearning about healthcare development

Action research – with (not on) carepractitioners

”The knowledge that is generated shall be both scientifically relevant, and relevant for practitioners. You must be able to use it, and act on it.”

Collaboration throughresearch

• Patient oriented and integrated cancer care processes

• In Search of Sustainable High Quality Health Care

• Decision support system for Warfarin treatment

• Experienced Based Co-Design – to involve patients, relatives and staff in a joint improvement work

• Patient complaints as a basis for improvement work

• Chest-pain – variation in quality, safety and cost

• System dynamics at a Dermatology Department

• Learning micro systems in healthcare processes

• The application of Lean Six Sigma in a healthcare context

• When process orientation meets the functional structures

• Analyses of medication processes

• Prognosis and and tactical planning within surgery

• Reimbursement models and process effectiveness

Action research with interdisciplinary staffing

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Collaboration througheducation

Professional education

• Quality driven organizational development (30 credit)

• Quality Management for senior managers (7,5 credit)

• Advanced improvement knowledge (30 credit)

• Lean healthcare (7,5 credit)

• Improvement knowledge for residents (7,5 credit)

PhD education

– Reflexiv action research (7,5 credit)

– Quality Management (7,5 credit)

– + other courses at Technology Management and Economics

CHI has trained more than 250 managers and improvement leaders within Region Västra Götaland

Education as a catalystfor change

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ApproachesOrganizing and managing

• Principles for organizing, organizational learning, how to deliver value, organizational change…

Data-driven operational development• Applied statistics, ”from data to improvement”,

visualization…

Processes and flow• Value focus, capacity planning, coordination,

integration…

Improvement knowledge• Variation, systems understanding, psychology…

Sustainability• Social, financial, environmental…

Action oriented • Action research – interactive research

• Experiential learning

Reduce variation in INR of patients undergoing warfarin

treatment as a way to eventually decrease mortality

and morbidity

Warfarin treatment• Warfarin – an oral anticoagulant (blood thinning) treatment

effective for the prevention of thromboembolic events in various clinical contexts.

• Serious risks related to Warfarin treatment, thus requiring great care and caution when ordinating Warfarin pills to patients.

• Patients undergoing Warfarin treatment are therefore monitored regularly by blood testing.

• International Normalized Ratio (INR) is usually used to measure the effect of Warfarin treatment.

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International Normalized Ratio (INR)

coagulation time of patient plasma

coagulation time of normal plasma

ISI

INR

• The standard INR range (also called the therapeutic range) for most clinical situations is 2.0-3.0.

Freq

uenc

y

87654321

5000

4000

3000

2000

1000

0

Histogram over INR-values at SkaS in 2005

Probable causes of variation in INR

30%

17%

11%

11%

7%

7%

6%

4%2%

5%

At start up

Drugs added/withdrawn

Ordination routines

Dr doesn't know of ordination

Concurrent disease

Information to patient

Patient compliance

Interruption routines

Lab variation

Other

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VCHEN (INR: 60%)

SiF (INR: 70-75%)

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160140120100806040200

5

4

3

2

1

0

Time in days

Y-D

ata

INRTablets/day

Variable

Plot of INR and number of tablets/day

Hemolysis

Vacutainer canula

constant dimension

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Venflon with Vacutainer adapter

Note all dimensional changes

Datum

And

el h

emol

ys

2007

-10-1

3

2007

-10-0

7

2007

-10-0

1

2007

-09-2

5

2006

-10-0

9

2006

-10-0

3

2006

-09-2

7

2006

-06-1

3

2006

-06-0

7

2006

-06-0

1

2006

-05-2

6

0,20

0,15

0,10

0,05

0,00

_X=0,0317

UCL=0,0808

Före förändring Efter förändring uppföljning efter 1 år

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Andel hemolys före och efter förändring

” The Skaraborg Hospital Group (SkaS)……..//……. Using an action research approach, thisarticle describes the lessons thatwere learned from the first 22 Six Sigma projects, completedbetween 2006 and 2008 and having a success rate of 75%.”

Net cost savings per project = 40 000 €

Lifvergren S, Gremyr I, Hellström, ChakhunashviliA, Bergman B(2010) Lessons from Sweden’s firstlarge-scale implementation of Six Sigma in healthcare. Oper Manag Res 3:117–128. DOI 10.1007/s12063-010-0038-y

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ApproachesOrganizing and managing

• Principles for organizing, organizational learning, how to deliver value, organizational change…

Data-driven operational development• Applied statistics, ”from data to improvement”,

visualization…

Processes and flow• Value focus, capacity planning, coordination,

integration…

Improvement knowledge• Variation, systems understanding, psychology…

Sustainability• Social, financial, environmental…

Action oriented • Action research – interactive research

• Experiential learning

A physician-led, and learning driven approach to the regional

development of 23 cancer pathways in Sweden

The cancer challenge• Every third person in Sweden at some point in their lives has experience

of cancer. That amounts to 50 000 patients a year = one new admission every ten minutes.

• Projections suggest that the number of men with cancer in 2030 will be almost 130 % more than today - the corresponding increase for women is around 70 %.

• Cancer care is:– highly decentralized – involves most levels of care. – highly multi-professional activity– fragmented– long and varying delays – a general lack of patient orientation.

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• 4 Patient centred criterias• 3 Criterias regarding training, knowledge

management and research• 3 Criterias regarding the organizing of RCCs

National cancer strategy

Learning about healthcare developmentLearning about healthcare development

”The knowledge that is generated shall be both scientifically relevant, and relevant for practitioners. You must be able to use it, and act on it.”

Centre for Healthcare

Improvement

Regional Cancer Centre West

Project Design

Agreed-upon core principles… so far

• Patient focused• Physician-led• Learning driven• Systems approach• Positive and opportunity-driven• Research informed

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Bladder cancerBrain tumorBreast cancerCervical cancerCervical cancer preventionChildhood cancerColorectal cancerColorectal cancer screeningCorpus cancerEarly detectionEsophageal cancer

Gastric cancerHead and Neck cancerKidney cancerLeukemiaLiver cancerLung cancerLymphomaMalignant skin tumorsOvarian cancerMammography

MyelomaPalliative carePancreatic cancerPenile CancerPrimary tumor unknownProstate cancerSupportive careThyroid cancerVulvar and vagina

A process oriented viewPatient process

Care team

Regional process group

Regional cancer centre

Community Control

CureCare

Customer

4 + 1 C

Glouberman & Mintzberg 2001

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Customer involvement• Experience-based codesign (patients and close relatives)• Patient Associations• Patient diaries• Young Cancer• …

Appreciative Inquiry: 4 + 1 C

• Different ways of creating value (value logics)• Resource consumption (CPP-data)• Effectiveness and production planning• Developmental dialogues• Early detection• Palliative care• Support for cancer survivorship• Patient diaries• KPI for tumour processes• …

Support for innovations- ongoing initiatives

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Value logic – production logic• We need different production logics to create value for

our patients–”How we organize people, competences, services,

standards and procedures at at a certain time in the system”

Sven, 62• No earlier diseases• Former football player• Accelerating pain from left hip• Severe arthrosis• Needs:

–New hip prosthesis including a swift, efficient and safe process

Process: Hip replacement

Diagnos Preparation Operation

Rehabilitation Final evaluation

Need:•New hip

Output:•Improvedfunction•No pain

•Arthrosis

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Anna, 40• Discovered a tumor in left breast• Needs:

–Immediate diagnos –Plan for futher treatment–Relieve anxiety

(One-stop) Solution workshop – Patient center

Specialist-läkare

Specialist-ssk

Specialist-läkare

Specialist-ssk

Specialist-läkare

Specialist-ssk

Specialist-läkare

DiagnosCare plan

Örjan, 76• Diabetes and congestive heart failure for many years• Severeal visits to in- and outpatient clinics• Needs:

–Safety and good quality of life at home–No admittances to the hospital–Be able to monitor and ”treat” exacerbations at

home–A trustworthy contact nurse, easy to get hold of–Be able to meet other patients with similar

experiences

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Network logic

• Self monitoring• Patient co-produces care• Coordinating centre• Mobile teams

Healthy elderly people

Elderly people withone or two stable chronic

diseases and taken care of by the ’ordinary’ care system

Elderly people with multiple chronic diseases but in stable condition and taken

care of by the ’ordinary’ care system

Elderly people with multiple chronic diseasesin unstable condition and taken care of by the

integrated mobile care team

7% of elderlypopulation

0.2%

Figure 2. Conceptual figure developed by the team together with the researchers that illustrates the different proportions of elderly people with different care needs in the actual area

Lifvergren et al. (2012) Learning microsystems in Healthcare

Different business models

• High volume, high quality, low cost

• Unique service, one stop shop

• Health promotion, prevention, upstream, behavioral aspects

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Primär prevention

Screening hälsokontroll

Palliativ vård

Symptom-utredning

Diagnos

Behandlings-utredning

Primär behandling

Tilläggs-behandling

Individuell vårdplan

Rehabilitering

Kronisk sjukdom

Psykosocialt stöd

Uppföljning behandling

ApproachesOrganizing and managing

• Principles for organizing, organizational learning, how to deliver value, organizational change…

Data-driven operational development• Applied statistics, ”from data to improvement”,

visualization…

Processes and flow• Value focus, capacity planning, coordination,

integration…

Improvement knowledge• Variation, systems understanding, psychology…

Sustainability• Social, financial, environmental…

Action oriented • Action research – interactive research

• Experiential learning

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0

25

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# o

f d

ea

th-f

ree

ca

se

s b

etw

ee

n

Death case #

g-chart

# of death-free cases between UCL CL LCL

Deaths, Miami Children

-0,20000

-0,10000

0,00000

0,10000

0,20000

0,30000

0,40000

0,50000

0,60000

1 110 219 328 437 546 655 764 873 982 1091 1200 1309 1418 1527 1636 1745 1854 1963 2072 2181 2290 2399 2508 2617 2726 2835

EW

MA

Surgery #

EWMA chart

EWMA

UCL

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t-chart (övervakning av hjärtstoppsförekomst) - utan HIVA

0

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HjS1

HjS2

HjS3

HjS4

HjS5

HjS6

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HjS8

HjS9

HjS10

HjS11

HjS12

HjS13

HjS14

HjS15

HjS16

HjS17

HjS18

HjS19

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Hjärtstopp nr

Tid

me

llan

hjä

rtst

op

ps

fall

(an

tal d

agar

)

t Sö CL Su

Önskvärd riktning

ApproachesOrganizing and managing

• Principles for organizing, organizational learning, how to deliver value, improvement work…

Data-driven operational development• Applied statistics, ”from data to improvement”,

visualization…

Processes and flow• Value focus, capacity planning, coordination,

integration…

Improvement knowledge• Variation, systems understanding, psychology…

Sustainability• Social, financial, environmental…

Action oriented • Action research – interactive research

• Experiential learning

For more info:

www.chi.chalmers.se