Value Development
and Productivity as
Keys in
modernizing and
co-designing health
and care
Quality as Business
strategy.
When art meet science, Singapore Sep 2016
http://www.marinabaysands.com/museum/future-
world/town.html#BfIhrXsybsKFxAPQ.97
• Thank you!
• Singapore
• Iceland
• Sweden
Alexandra Primary’s
RJL fantastic colleagues… in different microsystems
They love their work as complexists and futurists
Work with the work!
• From volume to value
• Focus on
experiences and
outcomes and
reducing cost
• Search for new
models
2016-10-28
The new ideas ……
• Individuals and families are partners in
their care and care processes
• Competition about value , with continuous
reduction in operating costs
• Reorganize services to align with new
incitaments ideas and process redesign
• Everyone is an improver/learner
2016-10-28
• ‘It is not enough to do your best; you
must know what to do,
and then do your best’ W. Edwards
Deming
• "Organising is a form of leadership that
enables a constituency to turn its
resources into the power to make
change." Marshall Ganz
• "The goal is to turn data into
information and information into
insight." Carly Fiorina
Assurance: The Four Leadership Questions
• Do you know how good you are?
• Do you know where you stand relative to the
best?
• Do you know where the variation exists?
• Do you know the rate of improvement over time?
Region
Jönköping
County
1)More engaged,
activated patients and
better health outcomes
2)Better knowledge of
one’s illness and
capacity for self-
management
3)Health systems
adopting processes
and achieving
outcomes that matter
to patients
4)Find ways of
managing healthcare
costs
Redefining Health Care – Creating
value based Health Care, p 376-377,
Porter,Teisberg
• ”In tertiary care Sweden has national
competition…….Swedish hospitals vigorously pursue
quality improvement, with ongoing benchmarking ,
against world best hospitals. The results of this
competition on value are striking. In one of the most
progressive lans, Jönköping, for example, the rates of
infection and mortality from errors are about one-fifth
of those leading American hospitals for patients with
the same conditions”
• Easy to have a healthy lifestyle here
• Healthcare at the top of the league
• Clean air
• Green areas
• Healthy food
• Excellent public transport
According to this report:
One of ten
healthiest areas
in the world
Please see me
https://www.youtube.com/watch?v=380MiMDoddI&app=desktop
Anette Abrahamsson, Annmargreth Kvarnefors and Göran Henriks
……
Treat me like a fellow human being
Give me knowledge
Look into my eyes
and imagine you are me
Listen to me
Talk with me, not to me
Let my family
be part of my health care
Meet me with respect
……
Let me be a part of my own care
Don’t let me be reduced
Change the Balance of Power • Ryhov Hospital in Jönköping had traditional hemodialysis
and peritoneal dialysis center.
• But in 2005, a patient, Christian, asked about doing it
himself.
Taking ”self-management” to the edge
Patrik Blomqvist, patient supporter Eje Grennborg, rehab instructor
New ways of making the consultations
Koloncancerprojekt
The Microsystem Festival March 1–4 2016 plus.rjl.se/microsystemfestival
• https://vine.co/v/iTPjpdYWWXn
2016-10-28
2016-10-28
(ange enhet via Infoga sidfot)
To create a better everyday life for the many people/IKEA.com
Patient focused ”activities and part of processes
are organized after Prioritated patient values"
Pat söker primärvården
Undersökning primärvården
Undersökningar Sjukhuset
Diagnos & beslut om åtgärd PV/ Sjukhuset
Rehabilitering Primärvården
Behandling Sjukhuset
Rehabilitering Kommunen
Esther Primary care areas (6)
Rehab Akuten Medicin
Högland hospital
Communities (6)
Traditional "functional"
patient
treated pat
ill
Lab
Pharmacy
Esther From traditional healthcare to Process thinking
Hospital admissions fell from approximately 9,300 in 1998 to
prognostic 7,300 in 2003.
Hospital days for heart failure patients decreased from
approximately 3,500 in 1998 to 2,500 in 2000.
Waiting times for referral appointments with neurologists
decreased from 85 days in 2000 to 14 days in 2003.
Waiting times for referral appointments with
gastroenterologists fell from 48 days in 2000 to 14 days in
2003.
Esther-results
2016-10-28
Your impression as a whole – largest amount of
positive answers in the whole of Sweden: Rydaholm
2016-02-09 Regionlednigskontoret
Net cost development accumulated adjusted
Region Jönköping lower than average
average
Health Care as a complex system
2016-10-28
• A large number of interactive units
• The interactions are nonlinear, small changes can
have major consequences
• The systems are dynamic, the whole is greater
than the sum of its parts, and the solutions can
not be imposed
• The systems have a history, and the past is
integrated with the present, the units changed,
and the changes are irreversible
• Wisdom does not lead to proactivity because
external conditions and systems change all the
time
Challenges that changed the roles and
functions of doctors and nurse
• Before 1910 Craftsmen and apprentices
• 1920 Scientific bases grows
• 1980 Understanding of system
performance
• 1990 Costs
• 2000 Accountability and transparency
• 2010 The care you receive depends on
where you live, not what you need
• 2015 Health - what generates health
Health and Care
Wellness Prevention
Diagnostics Treatment
http://www.svd.se/en-trist-trappa-forvandlas-till-ett-piano-leklust-och-fortrollning
Peoples actions are not directed by external
factors as rules and instructions
Instead the actions seems to be based on
peoples own understanding of the situation
Sandberg, J. & Targama, A. (2013). Ledning och förståelse Lund: Studentlitteratur
For both professionals and patients - Essence of co-learning
What matter´s to you?
”All services are in one or the
other way co-produced, co-
designed”
- We need new models of care!
2016-10-28
Utvecklingskraft 2016
Maureen
Defining Patient Involvement
Image courtesy of Region Jönköping
County
Thepa entinthecenter Thepa entasapartoftheteamandtheirneedsandpreferencesatthecenter
Pa entneedsandpreferences
A new way of thinking – value logics
• We develop value by better meeting the
wholeness of the patients and relatives needs
– Different groups have different needs
– The same citizen have different needs during
the toal lifecycle
• How do we collaborate to meet the different
patients groups needs and increase the value of
the services?
2016-10-28
(ange enhet via Infoga sidfot)
• Normann R. Reframing business: when the map changes
the landscape. Chichester, UK: Wiley, 2001.
• Bate P, Robert G. Bringing user experience to health care
improvement: the concepts, methods and practices of
experience-based design. Oxford: Radcliffe Publishing,
2007.
• Armstrong, Lisa Opipari-Arrigan and Hans Hartung Maren
Batalden, Paul Batalden, Peter Margolis, Michael Seid, Gail
Coproduction of healthcare service BMJ Qual Saf published
online September 16, 2015
Promote health and prevent illness
Parents
education
Palliative
care
Children with
different care
needs
Fragile elderly
multi disease
Now
Tomorrow
Karl, 62
• Earlier totally healthy
• Active sportsman
• Last 3 years pain in the hip
• X-ray shows a bad hip
• Need to get a new hip quickly
Funktionella resultat Kliniska resultat Resultat patienterfarenheter
Resourcescosts
Regional medicinsk programgrupp ortopedi Resultatrapport utifrån Värdekompass
Sydöstra sjukvårdsregionen
• Funktionella resultat EQ5D i samband med
höftledsplastikkirurgi och ryggkirurgi
(diskbråckskirurgi och spinal stenoskirurgi)
• Promenad – diff preop/1 år postop (spinal
stenoskirurgi)
• Upplevd bensmärta - diff preop/1 år postop
(diskbråckskirurgi)
• Oönskade händelser inom 30 dagar efter
knä- eller höftprotesoperation,
• Djupa infektioner (Infektionsverktyget)
• Höftledsplastikkirurgi
- Reoperationer < 2 år
• Höftfraktur
- Andel protesopererade
- Väntetid akutmottagning – operation
• Relativ revisionsrisk 10 år knäprotes
• Andel i höftartrosskola
• Tillgänglighet
Aktuellt väntetidsläge ur Väntetider i
vården
• Patientnöjdhet
- Upplevd nöjdhet ett år efter
höftledsplastikkirurgi
- Delaktighet, bemötande, information,
tillgänglighet, upplevd nytta, för-
troende, ur NPE – nationella
patientenkäten
M Bergeling/2012
• Average length of stay in connection with the hip and knee
surgery
• Average length of stay associated with spinal disc surgery
and stenos-surgery
Resurser resultat
Motala har ej system som möjliggör
uppdelad data (höft/knä) 2010
M Bergeling/2012
Kommentar: En klar minskning av vårdtid över tid. Fortfarande stora variationer. Elektiva enheter kortaste vårdtiderna.
Hip replacement
Resurser resultat
Motala har ej system som möjliggör uppdelad
data (höft/knä) 2010
M Bergeling/2012
Kommentar: En klar minskning av vårdtid över tid. Fortfarande stora variationer
Knee replacement
M Bergeling/2012
Kommentar : Klart minskande trend. Ingen skillnad. Lika som riket.
Spinal stenos surgery
Elsa, 86
• Diabetes and heart failure for many years
• Many visits at the hospital
• Need
– Trust and good life quality in the home
situation
– Avoid acute visits to the hospital
– Contact with other patient with similar
experiences
Anette Abrahamsson, Annmargreth
Kvarnefors and Göran Henriks
Mobile Geriatric Team
• Film: youtube….
https://www.youtube.com/watch?v=lTfzq5FqATs
Prevention in several areas
simultaneously
Risk
of
fall
Risk of
pressure
ulcer
Risk of
mal-
nutrition
In hospital, primary health care, nursing home etc
Risk of
bad oral
health
Risk of
inconti-
nence
Care
prevention
Risk-
assess-
ment
Team
based
analysis
Preven-
tive
inter-
vention
s
Evalu-
ation
Dis-
charged
/
informa
-tion
Register in Senior alert
020406080
Oral ealth
0102030
Pressure ulcers
0
10
20
30
40Weightlosses
0
10
20 Falls
Actions
Pressure ulcers are reduced
Municipalitie
s
County councils
%
Region
Jönköping county Regions and
county councils Municipalities
Weightlosses >5% are reduced
2011-2015
municipalitie
s
County councils
• Municipalities: 14%→ 12%
• County councils: 5%→ 4%
Better oral health
Less oral problems
with
- oral mucosa
- teeth
- saliva
- gum
County councils
Municipalities
Percentage with at least one ”2” or ”3” in ROAG
Sweden knows more about risks
among the elderly (age 65+)
• Risk of fall 66%
• Risk of malnutrition 59%
• Risk of bad oral health 48%
• Risk of pressure ulcers 23%
• No risk 17%
Support to the citizens
2016-10-28
(ange enhet via Infoga sidfot)
Learning cafe for young Tomorrows open care
for young
Work to people with mental handicap
Passion for life
Health ambassadors
Dancing with young
And Parkinson
Value center
Surgent
Specialist
nurse
Oncologist
Contact
nurse
Radiologist
Socail
worker
Pathologist
Diagnostics and
treatment plan
Anna, 40
• Previously healthy
• Have in her breast that´s worrying her
• Need
– Need a diagnoses very quickly
– Clear information
– When treated?
– Quick and safe
– How long will the treatment last?
The patient's path through ERAS* *Enhanced recovery after surgery
Contact
and
decisions about
surgery
Preoperative Intraoperative Postoperative Follow-up
Preoperativ tarmrengöring
Antibiotika-profylax
Trombos-profylax
Förberedande information/rådgivning till
patient
Pre-
medicinering
Vätske- och kolhydrat-belastning
Näringsintag och
näringsstatus
Fasteregler
Förebygga illamående/kräkningar
Ventrikelsond
KAD-rutiner
Mobilisering
Tarm-stimulerande
medel
Epidural anestesi - EDA
Förebygga illamående/kräkningar
Vätske-behandling
Näringsintag (näringsdryck,
iv näring)
Läkemedel för smärtlindring
Förberedande information/rådgivning till
patient
Hemskrivnings
kriterier
Förberedande information/rådgivning till
patient
Granskning av följsamhet till riktlinjer och
resultat
Uppföljning efter
utskrivning/operation
Inregistrering i EIAS
Prevention Screening
Health c.
Symptom
investigation
Diagnos
Treatment
investigation
Primary
treatment Added
treatment Follow-up
Individual
careplan
Psychological and
social support Rehabilitation
Chronic
disease
Palliative
care
Update
• Now calculated costs at 50% of costs in other
hemo-dialysis units
• Complications dramatically reduced and
subsequent expensive care avoided
• Measuring success by “number of patients
working”
Good life close
Reference:
Österstad Ulf [email protected]
Carlsson Johan [email protected]
Larsdotter Charlotta <[email protected]>
Café House of Health – about life,
autonomi and authority
• For patients with chronic diseases and
relatives
• Focus on health and well-being
• Supports the living of life with chronic
conditions , maintaining autonomy
• The possibility of support and hope through
conversations with other people experience
Exnovation and resilience
• The day-to-day practice unfolds in
a space as normal to illegal, Ref:
Amalberti and colleagues
• A way the employees develops
collective competence (Boreham
et al., 2000) so they together can
make it possible for them to design
a net of safety procedures.
Learning and change
among the players,
and growth in their
sophistication about
each other, about the
issues, (Innes and
Booher, 1999: 12).
Very good Best possible
Patient satisfaction
Take care of the problems
Person centered care
Prevention and plan for the next
step
Reduce over, under and misuse
Standardize work and
specialization
Run faster/more resources
Everything everywhere
Good examples Faster diffusion – equal
care
Strategic principles
Healthier life
Radical
individualism
and social
trust
Together for best possible and equal care
All parts optimize health issues
Microsystem Patients and professionals
Meso
Primary care Medicine
Surgical
Psychiatric
Makro Governance
Before Tomorrow
• https://vimeo.com/163250855
• http://plus.rjl.se/infopage.jsf?childId=15028&nodeId=31716
Improved learning platforms
2016-10-28
Learning on the away
court
(within the platform)
Learning at home
Learning at home
and away Tests
(acting)
Tests
(acting)
Reflection
(dialogues)
Reflections
(dialogues)
Tests
(results)
Tests
(results)
Support knowledge
development
(for examples concept
renewal
Arbetsplatsresultat ur
ett patientperspektiv
Reference: Ellström
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