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Improvement work

A top down or a bottom up perspective?

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The true journey of discovery is not to the search for new sights and places, but to see

the old, familiar with new eyes.

Marcel Proust 1871- 1922. French Novelist

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Jönköping

Eksjö

Värnamo

Health care in Jönköping County: 3 hospitals, 34 primary care centers, dental care centers,

9 800 employees, 330 000 inhabitants

Europe

Sweden

Jönköping County

www.lj.se/qulturum

Topics for this session

• Quality as business strategy in Health care

• A micro system perspective

• Some balanced measures including patient experiences

• Example from our improvement work and how we have gone from patient focus to the patients focus. . .

www.lj.se/qulturum

The success story of Jonkoping – the short version

• Top 3 county councils for more than 5 years in a row – 2010 no 1.

• A culture of improvement is created –value based health care

• Number of study visits from sweden and abroad is increasing

• Government assignments to improve quality in health care and elderly care in 2009-2010.

www.lj.se/qulturum1992 1995 1998 2000 2001 2002 2005

• teams for patientneed

• Main stay processes• Certification of laboratory

• Balanced score card• Qulturum starts• Breakthrough series

•Leadership meeting for L/I• Diamondpicture• System thinking• Patient- safety

• Pursuing perfection

• System measures

You can describe the historyThe future must be created

Awareness

Processthinking

Redesign

Education

Movement

Full scale

• Swedish Malcolm Baldridge Award (QUL)• Total Quality Management

• Esther – Health care processreeng. (HPR)• Leadership program for physician

• Values based & improvement education

• Audit for medical evaluation• Leadership development

www.lj.se/qulturum

Balanced scorecard

QUALITY AS A BUSINESS STRATEGY

0%20%40%60%80%

100%

Economy

Process/productivityCustomer/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, 2004

Work in a smarter way!

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The vision of Jönköping County Council

”For a good life in an attractive region”

www.lj.se/qulturum

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

AccessHow we receive

Coopera-tion/flow

Clinical improveme

nt work

Patient safety

Medication

Learning and innova-

tion

Good finances

Reliability

Strategic Improvement areas

PreventionSelf-care

Leadership

Transformation broad and in depth

Start with the Need and develop New Working Processes

Experimental learning

www.lj.se/qulturum

Number of units in the diamond boxes 2009-2010

0

200

400

600

800

1000

1200

1400

1600

Learning andinnovation

Professionaleducation

Clinicalimprovement

patient safety Reliability Coorporation

Involving everybody – both in deep and wide

www.lj.se/qulturum

Learning yesterday

Learning focus we need more of

What matters

Knowledge spread

The knowledge

Leading by

Looking for knowledge

What its all about

Library Google

Act into new understanding

Learning and doing together

Lectures

Goal!

My self

Beeing saved Directly spread

Result!

The development of customer values

My development

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www.lj.se/qulturum

You can’t change what you can’t understand

Health care was in the old days simple, safe and ineffective

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.. . . While it is now. . .

complex, effective and potentially dangerous

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A day in a nurse life

• 150 organizational memos• 100 guidelines for care in the department• 30 unit based guidelines• 23 357 article about COPD• 70 089 articles about Lung cancer• 30 different salary criteria's for doing a good job.

No wonder it’s easy to get lost

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Professional knowledgeMedicine, nursing, economic . . .Individual skillsValues ethic

Improvement knowledge System Variation psychology of changes Action based learning and improving

Improvement of diagnosis and treatment

Improvement of processes and the system in healthcare

Increase the value for our patients

+

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The Microsystem – Where healthcare improves

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Microsystem

Definition• It’s the small frontline units which provides healthcare to

the community.• It is a small group of people who an a regular basis are

working together to provide care to a group of patients• It has both clinical as well as financial goals,

cooperating processes, shared information and together they create results.

Reference: Batalden, Godfrey, NelsonDarthmouth Medical school, NH, US.

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Working from within your clinical microsystem…

I

SL

Perf Pt

Leadership• Leadership• Organizational

support

Performance• Results• Process improvement

Staff•Staff focus• Education & Training• Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Batalden et al

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Which is the level of performance, intervention, measurement ?

Community, Market,

Social Policy System

Macro-organization

System

Microsystem(clinical,

educational, etc.)

Individual professional &

beneficiary System

Self-care

System

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Why do we not do what we know?

GenerellEvidensbased

knowledge+

specificsetting

Measurableimprovements

control for

context

inquire into

particular identity

balanced measures over time

Chose best plan

Act locally

Batalden, Davidoff (2007)

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www.lj.se/qulturum

Will -Values

-Driving forces

Ideas- on things to be better inspiration, good exempel

-Methods and tools

Execution-From power points to patient values

-Follow result and spread good ideas. Ref: Error today and error tomorrow

Berwick D. (2003) NEJM Vol 458, no 25

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Tasks

Purpose Syfte Varför finns

vi till? Vilket värde

ska vi skapa?

People/ medarbetare Hur nyttjar och

tillvaratar vi medarbetarnas kompetens på bästa sätt?

Hur involverar vi dem mer i utvecklingsarbetet?

Hur ökar vi medarbetarnas förståelse för sin uppgift?

Processer/ flöden

Hur lär vi oss mer om våra processer?

Hur använder vi

oss av resultatet? Hur blir vi bättre

på länkning?

Patterns/ mönster

Hur utvärderar vi variationer i det kliniska arbetet?

Att kartlägga, reflektera, samtala och försöka systematiskt förbättra

MMMiiikkkrrrooosssyyysssttteeemmmeeetttsss fffeeemmm PPP

Patienter Vilka är de? Hur väl känner vi

deras behov? Hur involverar vi

dem mer?

LS 1 LS 2 LS 3 LS 4

Start 5PIdentify teamRolls : CM, secr, Meas-, MethodLook for waste

Describe 5PIdentify focus for improvementPhoto-journeyBase-lineFiskbone-processmap

Start testingPDSAMeasures.

Feedback – publish at Qreflex.

Posters-presentation

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Månad

Pro

ce

nt

P

GS

A

Aktivitet Aktivitet Aktivitet Aktivitet Aktivitet Aktivitet Aktivitet AktivitetSTART SLUT

5. Outstandingresultats

1.Team is in place

2. ActivitiesNo changes

3. Smallerchanges

4. Significantimprovement

Awareness Understanding Ideas-tests Spread/learning

4-6 month

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How to create awareness of what is going on?

• Videos• Photos• Follow a collegue and observe • Ask for stories from patients and families• Benchmark other organizations• Walk a mile in the patients shoe• Ask question. 5 P guide.

www.lj.se/qulturum

Purpose Why are we

going to work?

What values shall we create?

People How do we use the

staff members competence in the best way?

Who are they? Skills and talant?

Processes/

How do we learn more about our processes?

How do we use

the results? How can we be

better at linking?

Patterns

How do we evaluate variation in clinical work?

To map, reflect, create a dialogue and systematically improve

MMMiiicccrrrooosssyyysssttteeemmmeeetttsss 555 PPP

Patients Who are they? What are their

needs? How do we

involve them?

Ref: Godfrey, Nelson,Batalden

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Poka Yota – Easy to do rightBefore … After……

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5 S (Waste)Before After

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Goal!What to achieve?

Is a change really an improvement?

What test do we think will lead to the goal?

measure!

ideas!

test!

Improvement model Nolan, Deming m fl

Plan

DoStudy

Act

PDSA-cirkelnPDSA-cirkeln

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Valuecompass

Clinical

Functionshealthstatus

Service

costs

1. What's important for the nurses and doctors?2.Whats important for the patient in the daily life?3. What's important in the meeting with the healthcare system?4. What does it cost? Which resources do we use??

www.lj.se/qulturum

Value compass Hiparthros

Ortopedic departmenetCounty council Ryhov

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Värdekompassen – Höftartroplastik

Clinical status

Functional status

Resources

Patiensatisfaction

EQ-5D

Djup och ytlig infektion i samband med primär elektiv höftledsplastikkirurgi - NFBLänssjukhuset Ryhov

2003 - 2010

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2003 2004 2005 2006 2007 2008 2009 2010

Djup infektion mål - <0,5%

Ytlig infektion - mål <5%

Väntetider höftplastikkirurgi Länssjukhuset Ryhov

2008 - 2010

0

5

10

15

20

25

Jan

Feb

Mar

Ap

r

Maj

Ju

l

Au

g

Sep

Okt

No

v

Dec

Jan

Feb

Mar

Ap

r

Maj

Ju

n

Ju

l

Au

g

Sep

Okt

No

v

Dec

Jan

Feb

Mar

Ap

r

Maj

Ju

n

Ju

l

Au

g

Sep

Okt

No

v

Dec

2008 2009 2010

an

tal

Höftplastik - upplevd funktion EQ-5D(medelvärde/tertial)

ortoped- och reumatologkliniken, Länssjukhuset Ryhov2005-2008

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

T1 2005 T2 2005 T3 2005 T1 2006 T2 2006 T3 2006 T1 2007 T2 2007 T3 2007 T1 2008 T2 2008 T3 2008 T1 2009 T2 2009 T3 2009

EQ

-5D

-vä

rde

EQ-5D diff preop 1 år

EQ-5D preop

Andel patienter som deltagit i/erbjudits höftskolaUtvärdering i samband med nybesök inför höftplastikkirurgi

Länssjukhuset Ryhov2007 - 2009

medel=18%

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

T1 2007 T2 2007 T3 2007 T1 2008 T2 2008 T3 2008 T1 2009 T2 2009 T3 2009

Patienter väntande på höftplastikkirurgi Länssjukhuset Ryhov

2008 - 2010

0

10

20

30

40

50

60

70

80

90

100

Jan

Feb

Mar

s

Ap

ril

Maj

Jun

i

Au

g

Sep Okt

No

v

Dec

Jan

Feb

Mar

Ap

r

Maj

Jun

Juli

Au

g

Sep Okt

No

v

Dec

Jan

Feb

Mar

Maj

Au

g

Sep Okt

No

v

Dec

2008 2009 2010

anta

l

höft totalt

>90 dgr

Andel höft/lår remisser åter utan åtgärdortoped- och reumatologkliniken, Länssjukhuset Ryhov

2007 - 2010

medel=29%

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

jan-jun 2007 jul-dec 2007 jan-jun 2008 jul-dec 2008 jan-jun 2009 jul-dec 2009 jan-jun 2010 jul-dec 2010

"Hur nöjd är med operationsresultatet" Patientupplevelse 1 år efter höftartroplastik

Ortoped- och reumatologkliniken, Länssjukhuset Ryhov2008--2009

medel=85,5

0

10

20

30

40

50

60

70

80

90

100

Vårddygn i samband med primär/elektiv höftplastikkirurgiandel vårddygn <6, operationsdag=dag1

Länssjukhuset Ryhov2007-2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

T1

T2

T3

T1

T2

T3

jan

=11

feb

=18

mar

=16

apr=

22

maj

=17

jun

=11

sep

=18

okt

=24

no

v=23

dec

=13

jan

=15

feb

=25

mar

=28

apr=

14

maj

=17

jun

=14

aug

=9

sep

okt

no

v

dec

2007 2008 2009 2010

www.lj.se/qulturum

"Hur nöjd är med operationsresultatet" Patientupplevelse 1 år efter höftartroplastik

Ortoped- och reumatologkliniken, Länssjukhuset Ryhov2008--2009

medel=86

0

10

20

30

40

50

60

70

80

90

100

425

904

204

614

168

206

854

329

621

332

857

296

315 98 91

556

378

715

634

278

114

386

856

377

177

339

899

573

487

796

763

576

671

645

928

713

699

999

349

278

293

325

497

013

276

547

354

744

7

Mkt aktiv man,smärtproblematik höft,

Man med spinal stenos, stora svårigheter att stå och gå (090330 läkarbesök)

Kvinna med benlängds-skillnad 2 cm

RA besvär flera övriga leder,

Kvinna -48

Kvinna -65Kvinna -42

Kvinna -24

Kvinna -29Kvinna -43

Kvinna -39Kvinna -30

Patient experience one year follow up

www.lj.se/qulturum

Djup och ytlig infektion i samband med primär elektiv höftledsplastikkirurgi - NFBLänssjukhuset Ryhov

2003 - 2010

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2003 2004 2005 2006 2007 2008 2009 2010

Djup infektion mål - <0,5%

Ytlig infektion - mål <5%

Clinical results

2 djupa infektioner t o m maj 2010

2 ytliga infektioner t o m maj 2010

Infection rates after hip arthros joint operations 2003-2010 (elective)

www.lj.se/qulturum

Vårddygn i samband med primär/elektiv höftplastikkirurgiandel vårddygn <6, operationsdag=dag1

Länssjukhuset Ryhov2007-2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

T1

T2

T3

T1

T2

T3

jan

=11

feb

=18

mar

=16

apr=

22

maj

=17

jun

=11

sep

=18

okt

=24

no

v=23

dec

=13

jan

=15

feb

=25

mar

=28

apr=

14

maj

=17

jun

=14

aug

=9

sep

=20 okt

no

v

dec

2007 2008 2009 2010

Mål

Fr o m jan 2009 mätning/månad

Medelvårdtid 2009 = 7,3 dygn

Ekonomi/resurs

Length of stay elective hip joint surgic% stayed less than 6 days

www.lj.se/qulturum

What is an improvement culture?

• 30 seconds – what is the smallest improvement your organization /unit has done in the last year?

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LEAN exemple OP/IVA Jönköping

From 3 moment to 1

Saves 1,5 h / day

Before… After…

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Some example

• Visualization

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www.lj.se/qulturum

The articles

www.lj.se/qulturum

We also do. . .

• Passion for life – elderly doing PDSA and improvements in order to have a beautiful ageing

• Senior alert – the first national Quality registry for prevent falls, pressure sores and malnourish amongst elderly

• From patient schools to learning café

• Patient diaries for new service innovations

• . . . E-health, shared care plan, care on the web. . .

www.lj.se/qulturum

www.lj.se/qulturum

There is a crack, a crack in everything – that is how the lights gets in

(Leonard Cohen)