Improving Patient Flows with an End to-End Approach
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Transcript of Improving Patient Flows with an End to-End Approach
Improving patient flowswith an End-to-End approach
Mikael ForssDeputy CEO
Katarina Andersson, Gustav Hjelmgren, Olof VallinChange agents, Operations Management
Karolinska University Hospital- one of the largest hospitals in Europe
Solna Huddinge
15 miles
600 patients/day in our ED:s1,680 beds109,000 admissions/year1,7 million patient visits/year
County council owned• Patient care• Research• Education
15 000 employees
Karolinska´s main strategies
Change culture and daily routine work– Create safety culture– Improve leadership
Lean transformation– Process orientation and continuous improvements– Develop process oriented management– Change in culture as a result
Create Academic Health Care System in Stockholm– Strengthen clinical research– Increase cooperation between health care, academy and industry
3
4
Learning by doing 1993-2007
1993-1996
Outpatient ClinicDpt of Cardiology
1997 – 2004
End-to-End approachMaternity care
Top down & bottom up
2005-2007 2007
120 improvement projectsTQM, Six Sigma, SPC, LEAN85 % success rate short term
Long term?
Huddinge Hospital St Görans HospitalKarolinska
The merger
+
End-to-End approachED/Ward
Top down & bottom up
Days
2010
Delivery ward Maternity ward BA
Maternity ward A
A
Labour painsReferral to first assessment
End-to-End approach
ED Ward
X-rayLab
X-rayLab
OR
Our improvement modelQ
Phase 1RedesignTest/Learn
Phase 2Implementation
Phase 3ContinuousImprovement
Time
Value stream management system
ED Ward
X-rayLab
X-rayLab
ORValue stream leaderImprovement team
Value streammanagement team
Value stream management in practice
Current status
ED*(16)
Ward*(19)
X-ray* (5)Lab* (2)
X-ray (5)Lab (2)
OR(2)
16 patient flows:•Internal Medicine•Surgery•Orthopeadics•Gynecology•Ear-Nose-Throat•Pediatrics•Infectious diseases•Neurology95% of ED patient flow
* Statistically significant changes in patient oriented measures
Improved ED patient experience
%0 20 40 60 80 100
”Always/Almost always” got help when needed
Should ”on the whole” recommend Karolinska University Hospital
” On the whole” organised in a good way
”Acceptable” waiting time to see a physician
See a physician within 30 minutes
”Acceptable” waiting time to see a physician
”On the whole” satisfied with information about the medical condition
Was given information about expected waiting time to physician evaluation
Cooperation of the work force ”Very good”
Left the ED within 3 hours
20072009
All significant changes in the patient inquiry 2007 to 2009 are presented above
End-to-End LoS for admitted patients
jul 20
10
jan 20
10
jul 20
09
jan 20
09
jul 20
08
jan 20
08
jul 20
07
jan 20
07
jul 20
06
jan 20
06
78:00
72:00
66:00
60:00
54:00
48:00
Months (jan 2006 to oct 2010)
End-
to-E
nd L
oS (
mea
n)
Before Impl ED:s Impl first ward
Arrival at the ED until leaving the hospital for admitted patients10 wards at Karolinska 24/7
Door-to-doctor time
30 min reduction 24/7
40 min reduction weekdays 8 AM – 4 PM
2010
-42
2010
-17
2009
-45
2009
-20
2008
-47
2008
-22
2007
-49
2007
-24
2006
-51
2006
-26
2006
- 1
2:00
1:40
1:20
1:00
0:40
0:20
0:00
Week (2006-1 to 2010-42)
Doo
r-to
-doc
tor
(mea
n)Before Tests Implementation
Door-to-doctor time16 ED:s at Karolinska 24/7
Number of patients waiting for doctor each hour
Patients
Hour
Discharged before 12 AM
2010
-18
2009
-45
2009
-20
2008
-47
2008
-22
2007
-49
2007
-24
2006
-51
2006
-26
2006
- 1
40%
30%
20%
10%
0%
Week (2006-1 to 2010-42)
Dis
char
ged
befo
re 1
2 A
M (
mea
n)
Before Tests Implementation
10 wards att Karolinska University Hospital 24/7
X-ray total turn-around time
jul-se
p 201
0
jan-m
ar 20
10
jul-se
p 200
9
jan-m
ar 20
09
jul-se
p 200
8
jan-m
ar 20
08
jul-se
p 200
7
jan-m
ar 20
07
jul-se
p 200
6
jan-m
ar 20
06
3:20
3:00
2:40
2:20
2:00
1:40
Quarter (jan 2006 - sep 2010)
Tota
l tur
n-ar
ound
tim
e (m
ean)
Before Significant change
Time from first doctor asessment to avaliable X-ray result CT Brain at all ED:s in Karolinska Solna 24/7
Clinical Chemistry total turn-around time
okt 2
010
aug 2
010
jun 20
10
apr 2
010
feb 20
10
dec 2
009
okt 2
009
aug 2
009
jun 20
09
apr 2
009
feb 20
09
dec 2
008
okt 2
008
2:10
2:00
1:50
1:40
1:30
Months (oct 2008 - oct 2010)
Tota
l tur
n-ar
ound
tim
e (m
ean)
Before Significant change
Time from first doctor asessment to last available test-result at visitClinical Chemistry testing at all ED:s in Karolinska Solna 24/7
Financial results at Karolinska 2005 - 2010
18
Learning by doing 1993-2010
1993-1996
Outpatient ClinicDpt of Cardiology
1997 – 2004
End-to-End approachMaternity care
Top down & bottom up
2005-2007 2007
120 improvement projectsTQM, Six Sigma, SPC, LEAN85 % success rate short term
Long term?
Huddinge Hospital St Görans Hospital Karolinska
The merger
+
Swedish LEAN AwardSt Görans Hospital
End-to-End approachED/Ward
Top down & bottom up
End-to-End approachED/Ward
Top down & bottom upSupport processes
Days
2010
Delivery ward Maternity ward BA
Maternity ward A
A
Labour painsReferral to first assessment
Sustainableimprovements
2512262011761511261017651261
1:50
1:40
1:30
1:20
1:10
1:00
Week (2006 - 2010)
Doo
r-to
-doc
tor
Sustainable improvements
Challenges from the CEO`s perspective• Other projects
• Make priorities• Continuous productivity improvement
• To involve the whole organisation• Leadership• Staff involvement
• The change agents risk become ”burned”
• Why lean transformation – only to become more effective?
We have set up a value stream management system which sits parallel toour line management structure. We have also put in place supporting structuresincluding an operations management team, improvement teams consistingof staff members, written work standards, procedures for handling deviations,visual management as well as comprehensive data support.
BUT our senior management team is not yet fully committed and has notinvested enough time in learning of LEAN principles and the design of aLEAN transformation. They also do not invest enough time at the ”Gemba” to learn, or intheir managements team meetings to follow up. As a result, some of theirdirect and indirect report areas are also less than fully committed.
The situation is starting to change, but we would like your advice how we can inspireand engage the senior management to get more involved and committed to make the LEAN transformation a core part of their agenda?
Current problem