Post on 31-Mar-2015
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).
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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
!
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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
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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