Improvement work
description
Transcript of Improvement work
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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
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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. . .
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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
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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”
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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
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
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Number of units in the diamond boxes 2009-2010
0
200
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Learning andinnovation
Professionaleducation
Clinicalimprovement
patient safety Reliability Coorporation
Involving everybody – both in deep and wide
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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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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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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
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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
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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.
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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??
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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%
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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
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25
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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
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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%
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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
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Feb
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s
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Maj
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i
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v
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r
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Juli
Au
g
Sep Okt
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v
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Jan
Feb
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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
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20
30
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100
Vårddygn i samband med primär/elektiv höftplastikkirurgiandel vårddygn <6, operationsdag=dag1
Länssjukhuset Ryhov2007-2010
0%
10%
20%
30%
40%
50%
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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
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"Hur nöjd är med operationsresultatet" Patientupplevelse 1 år efter höftartroplastik
Ortoped- och reumatologkliniken, Länssjukhuset Ryhov2008--2009
medel=86
0
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40
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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
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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)
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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
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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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The articles
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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. . .
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There is a crack, a crack in everything – that is how the lights gets in
(Leonard Cohen)