change management at the karolinska university hospital using lean transformation birgir jakobsson...

Change management at the Karolinska University Hospital using Lean transformation

Birgir Jakobsson CEO

Karolinska University Hospital

2013-04-25

Global Health Care ChallengesHealth Care costs vs BNP per capita

Lean Method in University Hospital Setting. Helsinki April 2013

Lack of quality

Lack of integrationbetween academia,

industryand health care

Restricting rulesand regulations

Insufficient clinical pathways

Accidents and mistakes

Inefficiency

Demography

Differences in culture and conflicts

of interests

Källa: Value guided healthcare, The Boston Consulting Group, AB 2009Källa: Value guided healthcare, The Boston Consulting Group, AB 2009

Local Health Care ChallengeSome challenges are Health Care inhouse challenges

The Doctor. Sir Luke Fildes, 1891. The Tate Gallery, London.

Lean Method in University Hospital Setting. Helsinki April 2013

Cardiac surgery. (Foto 2003 © Johan Garsten, Karolinska Universitetssjukhuset).

5

Lean Method in University Hospital Setting. Helsinki April 2013

Sir Cyril Chantler:

“Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

Lancet. 1999; 353(9159):1178-81, p. 1181.

Lean Method in University Hospital Setting. Helsinki April 2013

according to Amalberti, R. Safety Science, 2001.

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High Risk OrganizationsHealth care organizations with high risk profile

Lean Method in University Hospital Setting. Helsinki April 2013

If we want different results – we have to do things differently

Huddinge University Hospital1995-2003

Lean Method in University Hospital Setting. Helsinki April 2013

LEAN – a strategy for improvement

A B C DA B C D R

A B C DA B C D RFlow-

PrinciplesPrinciples of Improvement

Lean Method in University Hospital Setting. Helsinki April 2013

See the whole picture Focus on patient value Eliminate waste

Capio S:t Görans Hospital 2003-2007

Lean Method in University Hospital Setting. Helsinki April 2013

Lean Method in University Hospital Setting. Helsinki April 2013

Reg.Kassa

SpotCheck

Diskenbed prio.av ssk

Läkareunders.

Leaves E&A

ProverEKG

Konsult

Rtg

Prover

Ny bed av läkare

* * *Treatment time 2:43Nr of pat kl 16: 7,5

Remiss

Svar

Svar

Klar

Parts of patient’s way through the E & Awhere waste (time) can be identified and refused by us

Important decisions

Ord

BehOrd

40 Hem 29

Inl. 10

Wait for dr 1:19Nr of pat kl 16: 3,7

Am-bulans

Triage

1. 55 min

4. 15 min

2. 30 min

3. 30 min

Where is the waste?Flow Chart of Emergency Surgery

Identified waste = 130 min

Lean Method in University Hospital Setting. Helsinki April 2013

Prototype for a new work procedure

Karolinska University Hospital 2007-2013

Lean Method in University Hospital Setting. Helsinki April 2013

Solna Huddinge

Karolinska University Hospital 2007-2013

Lean Method in University Hospital Setting. Helsinki April 2013

Number of patients seen by doctor per hr

Number of patients per hr

Patients way through E & A

Lean Method in University Hospital Setting. Helsinki April 2013

Inpatients arrive to

E&A

Patients leave ward

unit

Patients arrive to ward unit

Patient flow to and from an in ward unit

Lean Method in University Hospital Setting. Helsinki April 2013

How should we bring about CHANGE ?

Lean transformation

Strategic plattform

Leadership

Lean Method in University Hospital Setting. Helsinki April 2013

To improve patient value

1. Create more effective processes with better patient flow, shorter lead times, less faults and less waste

2. Create effective team work with safer communication

3. Secure that we use effective methods (EBM)

Method (EBM)

ProcessTeamwork

Staffing and rules

R&D

R&D

R&D

What did we want to improve?

Where do we start to improve?

Emergency flow

Imperative flow

Planned flow

Lean Method in University Hospital Setting. Helsinki April 2013

E&A Ward

1 23

We wanted to improve the processes with an ”end-to-end”-

perspective- but one step at a time

In which order should we improve?

Lean Method in University Hospital Setting. Helsinki April 2013

E&A Ward

1. Wait for doctor: 40 min2. Through time E&A 4hrs: 90%3. Nr of patients at 16 PM: 80

1. Patients to ward <4hrs: 90 %2. Discharge before 12 AM: 33 %3. Shorter AVLOS: 15 %

Goals and KPI’s?

Lean Method in University Hospital Setting. Helsinki April 2013

E&A Wards

X-rays/lab

X-rays/lab

Surgery

Early involvement of support processes

Lean Method in University Hospital Setting. Helsinki April 2013

E&A Wards

X-rays/lab

X-rays/lab

Surgery

Managementteam

Flow leaderImprovement groups

How to create a mixture of top-down and bottom-up?

Lean Method in University Hospital Setting. Helsinki April 2013

How to lead the improvement work?

FAS 1Framtagning

och test

Tid

FAS 2Implementering

FAS 3Ständiga

förbättringar

FAS 0Överenskommelse

Q

Lean Method in University Hospital Setting. Helsinki April 2013

Systematic approach to establish, standardize and improve work procedures

Lean Method in University Hospital Setting. Helsinki April 2013

Values

Principles

Way of working

Results

Flow rules Flow-principles

Go and see Standards

How to avoid too much focus on results?

Lean Method in University Hospital Setting. Helsinki April 2013

241217193169145121977349251

2:00

1:00

0:00

Konsekutiva veckor 2006-2010

Vänta

n p

å lä

kare

_X=0:49

UCL=1:03

LCL=0:35

Före Fas1 Fas2 Fas3

Mål

Waiting for doctor, 5 days a week, 08-16, in Huddinge

Lean Method in University Hospital Setting. Helsinki April 2013

Turn-around time <4hrs 5 days a week, 08-16, in whole hospital

Lean Method in University Hospital Setting. Helsinki April 2013

%

% of patients in ward within 4hrs from arrival to E&A, 12 wards

Lean Method in University Hospital Setting. Helsinki April 2013

%

% discharged before 12 AM,12 wards

Saved time in comparison with prioritized time (24h) 2010 to 2013, mars

Lean Method in University Hospital Setting. Helsinki April 2013

Principles

Way of working

Results

Wright from beginningStandardisationVisualisation

Values Mutual values

TeamworkWright competence in wright timeContinuous improvement

SafetyQualityAccessabilityWorking environmentEfficiency

Change of culture

SilosHierarcies

Single workSequensial

VariationUnpredictable

FuturePresent

For whom are we here

Predictable

Lean Method in University Hospital Setting. Helsinki April 2013

Three important challenges

Values

Flow efficience/ resource efficiency

Leadership

Lean Method in University Hospital Setting. Helsinki April 2013

Karolinska´s strategic plattform

Our assignment

Our Vision

Present

state

Long term strategies

Our values

Our valuesLong term

goals

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Lean Method in University Hospital Setting. Helsinki April 2013

Our vision

The patient always first

We provide care of

excellent quality and

safety

We are accessible,

effective and provide individual

care to our patients

We are role models within

R&D and education

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Lean Method in University Hospital Setting. Helsinki April 2013

Our values

Accountability Humanity Holistic attitude

Vi tar ansvar för våra patienter, uppgifter och varandra. We

speak up if we think something is wrong.

Vi möter våra patienter och varandra med

omtanke och respect. Vi utgår från varje

patients unika behov.

Vi arbetar tillsammans över gränser för att ge bästa möjliga vård. We value each others work and ask for help when

needed.

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Lean Method in University Hospital Setting. Helsinki April 2013

Values = tools to change culture

Performance

Attitudes and behaviour

!

38

Lean Method in University Hospital Setting. Helsinki April 2013

New Karolinska?

Quality/C

ost/Health

Flow efficiency

Quality/Cost/Health

VC/ResourcesV

C/F

low

s

Resource efficiency

Lean Method in University Hospital Setting. Helsinki April 2013

Flow efficiency versus resource efficiency

Resource efficiency

Flow efficiencyHigh

Low

High

Low

Start

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Lean Method in University Hospital Setting. Helsinki April 2013

1. Esatablish best standard

2. Standard should be folowed

3. Challence and support imrovement

of standard

Educates and motivates

Accountable for reaching goals

Lean and leadership

Lean Method in University Hospital Setting. Helsinki April 2013

Systems for learning, continuous improvement and long-term sustainability

Medarbetare

1:a linjechef

Verksamhetschef

Divisionschef

Sjukhusdirektör

Q

Patient value

Problemlösning på rätt nivå

Visualisering

Eskalering av problem som ej kan lösas på egen nivå

Värdeskapande aktiviteter

Ständiga förbättringar och

dagligt lärande

Efterfråga resultat och skapa

förutsättningar

Lean Method in University Hospital Setting. Helsinki April 2013

Karolinska will not only focus on results – we also have to build ”Health”

HealthResults

Our ability as an organisation to continously question and

challenge ourselves in order to reach sustainable results

”Coninuous improvement”

What do we achieve, production of care at the wright quality within

balanced economy

Lean Method in University Hospital Setting. Helsinki April 2013

Decrease in outpatient waiting times

Mål 2013 2015<300 0

Mål 2013 2015<400 0

Totalt utbetalt vite 2012: 18,9Mkr

Lean Method in University Hospital Setting. Helsinki April 2013

Patient satisfaction, E&A

0 20 40 60 80 100

"Alltid/nästan alltid" hjälp vid behov

"Helt och hållet" rekommendera K

"Helt och hållet" organiserat på ett bra sätt

"Acceptabel" väntetid för att träffa läkare

Fick träffa läkare inom 30 minuter

"Acceptabel" väntetid för att träffa specialist

"Helt och hållet" tillräcklig info om tillstånd

Fick info om beräknad väntetid till läkare

Personalens samarbete "Utmärkt", "Mkt bra"

Patienten lämnade akuten inom 3 timmar

2007

2009

%

47

Development of leadership 2006-2011

Lean Method in University Hospital Setting. Helsinki April 2013

48

Staff satisfaction 2006-2011

Lean Method in University Hospital Setting. Helsinki April 2013

49

Karolinska University Hospital – economic results 2005 - 2012Mkr

år 2005 år 2006 år 2007 år 2008 år 2009 år 2010 år 2011 år 2012

resultat -54 -191 -358 -250 115 181 58 35

-350

-250

-150

-50

50

150

250

Lean Method in University Hospital Setting. Helsinki April 2013

Conclusion

Standardisation

Transparence – visualisation

Patient value

Learning from errors

Continuous improvement

The developing leadership

Focus on quality/cost

Lean Method in University Hospital Setting. Helsinki April 2013

Contact information

Birgir Jakobsson, CEOKarolinska University HospitalStockholmSwedenE-mail: birgir.jakobsson@karolinska.se