Criminología , Santiago-Chile, Editorial Jurídica de Chile, 1998. sección sociologica
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Transcript of ISOC Santiago de Chile October 2011 On gains in efficiency, quality and safety in orthopedic...
![Page 1: ISOC Santiago de Chile October 2011 On gains in efficiency, quality and safety in orthopedic hospitals ISOC CEO Meeting Santiago de Chile, October 14,](https://reader035.fdocuments.in/reader035/viewer/2022070401/56649f1c5503460f94c32edc/html5/thumbnails/1.jpg)
ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
On gains in efficiency, quality andsafety in orthopedic hospitals
ISOC CEO MeetingSantiago de Chile, October 14, 2011
Peter Hoppener
Sint Maartenskliniek, The Netherlands
Pelle Gustafson
Skåne University Hospital, Sweden
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Agenda
Introduction and background 10.30 – 10.45
Short description 10.45 – 11.00
Lean
ToC
Six Sigma
Cases presented 11.00 – 12.00
Sweden
The Netherlands
Discussion 12.00 – 12.30
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Our most important problems:
- The economy
- Quality issues
- Safety issues
- Accessibility
- Future recruitment
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
1900 1950 2000
% of GDP$ per inhabitant
What healthcare has cost / will cost
What society has paid / will pay
Year
(adapted from WHO 2000)
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Quality issues
How do we know:
• how good we are (absolute measure)?
• if we are good enough (relative measure)?
• where we are not good enough?
• where we are better than good enough?
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Patient safety issues
Those who measured found:
• In around 10 % of all contacts with healthcare, the
patient was either in risk of harm or de facto harmed
• The fraction of care-related infections is around 10 %
• Swedish orthopedic department: 15 % of patients
experienced some kind of care-related harm (e.g.
infection, DVT, overfull urinary bladder)
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Patient safety issues
If a commercial airline operated with the same level of safety as
healthcare (10 %) …
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Patient safety issues
If a commercial airline operated with the same level of safety as
healthcare (10 %) …
we would consider it acceptable that during an ordinary
domestic flight 10 to 15 passengers were either at risk
of being harmed, or were de facto harmed…
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Patient safety issues
In 2010, one of 1 600 000 commercial flights ended in a crash…
How many of 1 600 000 elective operations ended in a crash?...
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Accessibility
Swedish healthcare has results and outcomes among the
best in the world…
Still, we were ranked 22nd in the world in 1999, and 16th in
Europe in 2006.
Why?
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
Future recruitment
Who will do the work?
A global shortage of 5 million healthcare workers is
estimated in the coming 10 to 15 years.
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ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011
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1304/20/23
Lean Healthcare
- what is it and how can it be used during surgery? -
Pelle Gustafson MD, PhD, COO
Department of Orthopedics
Skåne University Hospital
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1504/20/23
INTRODUCTION – what is Lean?
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1604/20/23
What is Lean (1)?
• Know your demand
• Separate “true demand” from “failure demand”
• Identify “value” and “non-value”
• Design against demand
• Eliminate waste
• Use the expertise of the employees
• Make sure learning is reintroduced into work
• Continuous improvement
• Keep customer in focus!
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1704/20/23
What is Lean (2)?
1. Find out what to do (know your demand)
2. Find out how to do it (agree on standard)
3. Do what is supposed to be done
4. Make it possible to identify flaws (why? x 5)
5. Improve process step-wise by using flaws
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1804/20/23
What Lean really is
Value setsAttitudesMindset
Value setsAttitudesMindset
Methods, tools
Principles
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1904/20/23
Our Lean history
• Serious work since 2007
• Done in line-of-command by chiefs/heads
• Internal staff- and education support
• Facilitators but no external consulting
• 5S in wards and outpatient clinic
• Hip fracture line
• Section of artroplasty
• Central operation ward
• Emergency department
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2004/20/23
Our common core valuesOur common core values
- The patient comes first- The patient comes first
- Respect the individual- Respect the individual
- Continuously better- Continuously better
All we do should be based on these 3 principles!All we do should be based on these 3 principles!
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2104/20/23
CENTRAL OPERATION WARD
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2204/20/23
Problems
• Capacity; 1 200 annual elective operations not enough
• Staffing; not fully staffed, high turnover
• Organization; recent change (2008-01-01)
• Quality, safety; not good enough
• Effectiveness; bad use of resources
• Many improvement projects tried over the years
• Giant frustration (expressed in many ways…)
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2304/20/23
Method
• Analysis of demand
• Correct planning
• Mapping of processes
• As much parallel work as possible
• Working group
• External facilitator
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2404/20/23
Analysis of demand
• We have to:
– do 1 600 elective orthopedic operations per year
– do all kind of orthopedic operations
– increase quality and safety
– incorporate continuous improvement in process
– do this in the same facilities and with the same staff
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2504/20/23
Correct planning
• We need to:
– 2 months ahead• know how many theatres we can use
– 3 weeks ahead• make coarse planning (name, operation, equipment)
– 1 - 3 days ahead• make detailed planning (process planning)
– during day• know what happens so we can plan next surgery
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2604/20/23
Mapping/designing of process
• Done by working group
• Swim-lane diagram useful
• Remove sequential work, replace with parallel work
• Make role descriptions
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2704/20/23
07:15 07:20 07:25 07:30 07:35 07:40 07:45 07:50 07:55 08:00 08:05 08:10 08:15 08:20 08:25 08:30 08:35 08:40 08:45 08:5007:55 op start 08:40 Op-slut
VårdavdFörbereda pat
inför op07.30 Pat 1 till
slussFörbereda nästa pat
Op uskSprita salen, ställa ass-
bord
Hämta opvagn + extrainstr o
ev impl
Assistera dukning
Assistera tvätta och klä
07:55 Operation
Beställa pat 2 + op-vagn + med tek bitr
Fika
Op ssk Läsa in sig på patient
Tvättar sig Duka Tvätta och klä07:55
OperationRäkna ner instrument
Fika
An uskStarta alla
datorerDuka fram till
anestesiHämta MT-utr
Ta emot pat i sluss
Förberda pat 1
Sövning pat 1
Hämta ev MT-utrustn pat 2
FikaInstrument t
sterilenMellanstäda Pat in på sal
An sskKontr av
apparat + Primus
Läsa in sig på pat och dra lm
x 5 pat
Ta emot pat i sluss
Förbereda pat i förb.rum
Sövning pat 1
Kopplar upp och övervakar pat. Dokumenterar
07:55 Operation
Koppla loss allt pat 1
Pat 1 till UVA, rapport
Fika
An läk Fika Pat in på sal
OperatörAnländer och
kollar checklista
Tvättar sig07:55
OperationKoppla loss
allt pat 1Diktera
Op ass Tvättar sig07:55
OperationKoppla loss
allt pat 1Pat 1 till UVA,
rapport
Med tekn biträde
Förbereda och markera op
bord
Opbord till sluss pat 1
Säng parkeras COP?
Förbereda och markera op
bord
Säng pat 1 till slussen
Opbord pat 2 till sluss
Städ
SterilenLeverera op-vagn pat 1 till
sterilförråd
Packa op vagn, pat 2
UVA
Rapport fr operatör och an ssk
07:15 07:20 07:25 07:30 07:35 07:40 07:45 07:50 07:55 08:00 08:05 08:10 08:15 08:20 08:25 08:30 08:35 08:40 08:45 08:50
Testdag 1, 18 maj, ortopedmodulen på COP (en sal)
Beräknad knivtid ca 230 minuterAnvänd modultid (minus lunch o fika): 400 minuterAndel knivtid per använd modultid: 58%Andel knivtid per 510 minuter (dvs max tillgänglig modultid): 51%
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2804/20/23
DESCRIPTION
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2904/20/23
Description
• Description of process:– Planning in several steps (early, 1-3 days before, during day)
– Preoperative meeting and planning
– The working group
– Deal, not order
– Descriptions of various functions
– Continuous improvement
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3004/20/23
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3104/20/23
Early planning
• Estimated need 1 600 elective operations per year
• COP gives note of capacity at least 2 months in advance
• 3 weeks before surgery– coarse planning (name, planned operation, need of equipment)
– how many operations (how much do we need or dare?)
– confirmed communication
– information spread to those who need:
• Central Operation Ward
• Unit for sterile goods
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3204/20/23
Planning 1 - 3 days before surgery
• Detailed planning
• What to do, when to do it
• Deal (not order!) is made
– on paper
– displayed on the walls in the theatre
– shared with those who now need to know:
• wards
• unit for sterile goods
• postoperative ward
• assistants / cleaning
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3304/20/23
Planning 1 - 3 days before surgery
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3404/20/23
Planning during surgery
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3504/20/23
Feed-back after surgery
• Directly during / after the day (“quick-fixes”)
• Afterwards in working group (systematic)
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3604/20/23
RESULTS
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3704/20/23
Start Finish Op-time (min) Change-over (min)• Before
op 1 08.34 08.52 18 79 op 2 10.11 11.07 56 116 (incl lunch 30 min)
op 3 13.03 13.33 30 70 op 4 14.43 15.18 35Total 139 235 average 78
• Afterop 1 08.16 08.38 22 32op 2 09.10 09.50 40 50op 3 10.40 11.04 24 94 (incl lunch 30 min)
op 4 12.38 13.42 64 50op 5 14.32 15.05 33Total 183 196 average 49
Feed-back 15 minutes
Op-time + 31 % (183/139)Change-over - 17 % (196/235, however one extra change)Average change-over - 38 % (49/78)Time for feed-backIncreased safety
Historical comparison
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3804/20/23
Soft results
• ”it's fun to work!”
• ”what a teamwork!”
• ”today we worked as a team!”
• ”intense but fantastic day”
• ”we have stopped waiting for each other”
• ”horrible, so stressing!”
• ”good to hear what has been done from the surgeon!”
• ”much cooler and softer work, I wonder why?”
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3904/20/23
Experiences
• The productivity can be increased by at least 30 %
• The patient safety can be increased
– common picture of what should be done
– less open doors, shorter communication chains
• Large improvement potential by team-work
• Several small improvements can quickly be found
• The predictability can be dramatically increased:
– large improvements for cooperating units
– large internal gains (eg. lunch breaks can be planned)
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4004/20/23
Lessons learned…
• Improvement not loved by everyone!
• Management needed!
• Frustrating to know it is possible but not see it happen!
• More behavioral science that technical solutions
– what should the cost be for not making / keeping a deal?
– take the ego out of the equation
– some people simply do not think in processes
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4104/20/23
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4204/20/23
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4304/20/23
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4404/20/23
More lessons learned…
• Standardization needed (positioning, draping, etc)!
• Computer or paper?
• Time not to be chased, but used to improve!
• Deals have to be kept!
• Do not forget to learn from what happened!
• Use the walls!
• Find balance between bosses involvement and not…
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4504/20/23
Present status
• At present halted due to renovation and ventilation works
• Restart in November 2011
• Most important changes:
– planning meeting same morning to enhance team-work
– more discipline throughout
– more feed-back to staff
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4604/20/23
What is it really about?
• Gather the group!
• Make deals about why, what, who, when, and how!
• Keep the deals!
• Make sure experiences are reintroduced!
• Be persistent!… there is no such thing as a Lean project – only Lean work …
… to carve mistakes in sand, and success in stone…(B Franklin)
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4704/20/23
”Don't have time, got work to do!!”
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4804/20/23
DISCUSSION, QUESTIONS